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 Westhills Village Health Care Facility during CMS and state inspections, most recent first.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A cook in an LTC facility failed to change gloves and perform hand hygiene while handling food and utensils during meal services, leading to potential cross-contamination. Additionally, the cook used a rag from a sanitizer solution instead of individual alcohol pads to clean the temperature probe between food items, contrary to facility policy.
A CNA in a long-term care facility was reported for providing undignified care to five residents, including forcing a stroke-affected resident to walk despite unsteadiness, embarrassing another during an outing, and displaying aggressive and unprofessional behavior. The facility's administrator was initially unaware of these issues, and the CNA was removed from the schedule pending investigation.
The facility failed to maintain infection control practices during wound care, nasal cannula care, and personal care. An LPN used the same gloves throughout a dressing change and did not clean equipment, while nasal cannulas were improperly stored. A CNA did not follow hand hygiene protocols during personal care, using the same gloves for multiple tasks and failing to wash hands after handling soiled items.
The facility failed to ensure call lights were accessible for two residents, leading to deficiencies in accommodating their needs. One resident, affected by a stroke, often found her call light placed on her non-functional side, while another resident's call light was on the floor, out of reach. Interviews with CNAs revealed inconsistencies in call light placement, and the facility lacked a policy on call light accessibility.
The facility failed to follow physician's orders for two residents. A resident with a knee procedure was not assisted according to weight-bearing restrictions, as the CNA did not use a gait belt or provide verbal cues. Another resident's wound care was improperly conducted by an LPN, who did not apply prescribed Santyl cream and used unprescribed gentamycin ointment, while also failing to maintain infection control practices. These deficiencies were acknowledged by the DON.
Two residents were not screened for a history of trauma upon admission to the facility. One resident had significant past traumatic events and exhibited behavioral changes, while the other had severe cognitive impairment and mild depression. The facility lacked a formal trauma assessment tool and policy, leading to a deficiency in trauma-informed care.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or omissions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Improper Glove Use and Temperature Probe Cleaning in Meal Services
Penalty
Summary
The provider failed to ensure proper glove use and temperature probe cleaning during meal services. During an observation, a cook was seen wearing the same gloves while handling various food items and utensils, including waffles, hot dogs, and serving plates, without changing gloves or performing hand hygiene. This improper glove use was observed during two meal services, indicating a lack of adherence to proper food handling protocols. Additionally, the cook was observed using a rag from a sanitizer solution to clean the temperature probe between checking different food items, contrary to the facility's policy, which required the use of individual alcohol pads for cleaning. The Food Services Manager confirmed that the preferred method was not followed, increasing the risk of cross-contamination. The facility's hand hygiene policy did not specify expectations for glove use, and the food temping policy required the use of alcohol pads, which was not adhered to by the cook.
Inappropriate and Undignified Care by CNA
Penalty
Summary
The report details a deficiency involving inappropriate and undignified care provided by a certified nursing assistant (CNA) to five residents in a long-term care facility. Resident 33, who had a stroke affecting her left side, reported being forced to walk to the bathroom despite feeling unsteady, and described the CNA's tone as uncaring. Resident 35 recounted an embarrassing incident during a facility outing and felt harassed by the CNA, who later questioned her about their relationship. Resident 31's spouse observed a change in the CNA's attitude, describing it as harsh and unprofessional. Resident 19 reported rudeness and neglect, with the CNA refusing to assist her to the bathroom and making inappropriate comments about her needs. Resident 24 and his spouse described the CNA as aggressive and unprofessional, noting her behavior at the nurse's station. The facility's administrator was unaware of these issues until the survey, expressing a desire for residents to feel safe and respected. The CEO and administrator confirmed the incident involving Resident 35 and noted that the CNA's professionalism had been previously addressed. The CNA was removed from the schedule pending an internal investigation. The facility's Resident Rights policy emphasizes the importance of maintaining residents' quality of life, freedom from abuse, and respect for their individuality and self-determination.
Infection Control Deficiencies in Wound and Personal Care
Penalty
Summary
The provider failed to maintain proper infection control and prevention practices during wound care, nasal cannula care, and personal care. During a dressing change for a resident, an LPN placed dressing supplies on an unclean surface, used the same gloves throughout the procedure, and did not clean or disinfect scissors before returning them to the treatment cart. The LPN admitted to not following the facility's dressing change policy, which required using a clean field, changing gloves between wounds, and cleaning equipment. In another instance, nasal cannulas for two residents were found lying on the floor or wrapped around a portable oxygen tank, which were not clean storage areas. An RN confirmed that these practices were not in line with infection control standards. Additionally, a CNA was observed handling a nasal cannula that had fallen on the floor without cleaning it before giving it back to the resident. The CNA acknowledged the need to clean the cannulas before use. Furthermore, a CNA assisting a resident with personal care failed to use gloves when handling a soiled brief, did not perform hand hygiene after removing gloves, and used the same gloves for multiple tasks. The CNA did not follow the facility's hand hygiene policy, which required handwashing before and after resident contact and after handling soiled items. The RN and infection control nurse confirmed that the CNA did not adhere to standard precautions during the resident's care.
Inaccessible Call Lights for Residents
Penalty
Summary
The provider failed to ensure that in-room call lights were accessible for two residents, leading to deficiencies in accommodating their needs and preferences. Resident 33, who had a stroke affecting her left side, reported that her call light was often placed on her left side, making it inaccessible. On the morning of the observation, she did not have her call light and had to holler to get the attention of a CNA. Despite being cognitively intact, as indicated by her BIMS score, she did not have a pendant call light that could have been worn around her neck for easier access. Similarly, Resident 12 was observed calling out for help because her call light was on the floor and out of reach, preventing her from using it to request assistance to go to the bathroom. Interviews with CNAs revealed inconsistencies in the placement and accessibility of call lights. CNA K mentioned using gray push call lights clipped to residents' shirts or placed on trays, while CNA L ensured call lights were within arm's reach or on bedside tables. CNA M described placing call lights under sheets or clipped to beds, but all CNAs claimed they would notice if call lights were out of reach during frequent checks. The Director of Nursing expected staff to place call lights within reach and ensure residents knew how to use them, but there was no policy addressing call light accessibility. This lack of a formal policy contributed to the deficiency in ensuring residents' needs and preferences were reasonably accommodated.
Failure to Follow Physician's Orders for Weight-Bearing and Wound Care
Penalty
Summary
The provider failed to ensure physician's orders were followed for two residents, leading to deficiencies in care. For one resident, who had been admitted with a left total knee arthroplasty explantation and other medical conditions, the certified nurse aide (CNA) did not adhere to the prescribed weight-bearing restrictions. The resident, who was supposed to maintain toe touch weight bearing (TTWB) with contact guard assistance, was observed transferring without a gait belt and without receiving verbal cues or instructions from the CNA. The CNA was unaware of the resident's weight-bearing restrictions, which were clearly documented in the resident's electronic medical record and on a report sheet at the nurses' station. In another instance, a licensed practical nurse (LPN) did not follow the physician's orders for dressing changes on a resident with wounds on the lower extremities. The LPN failed to apply Santyl cream as ordered and used gentamycin ointment, which was not prescribed. Additionally, the LPN did not maintain proper infection control practices during the dressing change, such as not cleaning the bedside table before placing supplies and not performing hand hygiene between glove changes. These actions were contrary to the specific treatment orders documented for the resident's wound care. The director of nursing and other staff acknowledged the deficiencies in both cases. The lack of adherence to physician's orders and proper procedures for both residents highlights a failure in ensuring that staff were adequately informed and compliant with the care plans. This resulted in deviations from prescribed care, potentially impacting the residents' recovery and well-being.
Failure to Screen Residents for Trauma History
Penalty
Summary
The provider failed to ensure that two residents, identified as 15 and 34, were screened for a history of trauma upon their admission to the facility. Resident 15, who was admitted on 10/17/24, had a history of significant life events, including a flood and a wildfire that destroyed her home, as well as a developmentally disabled son. Despite these events, there was no assessment in her electronic medical record (EMR) that screened for any historical trauma. Interviews with the social services designee (SSD) revealed that there was no formal assessment tool available to screen for trauma, and the SSD was unaware of the resident's past traumatic experiences. Additionally, the resident exhibited behavioral changes, such as refusing care and preferring female staff, which were not linked to any trauma assessment. Similarly, resident 34, who had a severe cognitive impairment and mild depression, was not documented as having been asked about any traumatic events. The social services coordinator and consultant confirmed that there was no documentation in the admission assessment indicating that trauma had been screened for this resident. The facility lacked a Trauma Assessment policy, and there was no expectation or process for screening residents for trauma or cultural preferences, as confirmed by the administrator and the director of nursing/infection control nurse.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 55 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | 1.6 mi | — | 6 | 0 |
| Avantara Mountain View | 2.4 mi | — | 5 | 0 |
| Avantara Arrowhead | 2.6 mi | — | 20 | 0 |
| Clarkson Health Care | 3.1 mi | — | 1 | 0 |
| Avantara North | 3.6 mi | — | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Westhills Village Health Care Facility.
100% money-back within 48 hours.
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.