Avantara Arrowhead

In the surveyor’s words

From the most serious findings on record at Avantara Arrowhead, in the surveyor’s own words.

• Actual harm, isolatedF684Jun 22, 2026

  A. Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, record review, and policy review, the provider failed to ensure physician's orders were entered in one of one resident's (57) electronic medical record (EMR) and implemented to mitigate that resident's risk for hospitalization. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include:1. Review of the provider's 3/16/26 submitted SD DOH FRI final report regarding resident 57 revealed that physician HH's 3/6/26 orders were noted (acknowledged as being read, understood, and entered in resident 57's EMR) by assistant director of nursing (ADON) P on that same date. […]

• Actual harm, isolatedF689Nov 6, 2025

  Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) reviews, interviews, record review, and policy review, the provider failed to ensure the safety of three of eight sampled residents (1, 2, and 3) who had incidents of falls related to equipment use between 9/11/25 and 11/5/25. The manufacturer's instructions and policies for safe use of the resident care equipment had not been followed by the staff. Findings include: 1. Review of a 10/24/25 SD DOH FRI revealed that resident 1 had fallen out of a bath chair in the bathing room. The root cause identified for that fall was certified nurse aide (CNA) C failing to secure the bath chair's safety belt around the resident's waist while the resident was seated in that chair. […]

• Actual harm, isolatedF684Sep 11, 2025

  Based on record review, interview, and policy review, the provider failed to ensure quality care by not promptly implementing physician-ordered treatments for one of one sampled resident (69) with a physician-ordered negative pressure wound (NPWT) and antibiotic medication treatment. Findings include: 1. Review of resident 69's electronic medical record (EMR) revealed:*Her admission date was 3/25/25.*Her 3/31/25, 7/1/25, and 7/29/25 Brief Interview of Mental Status assessment scores were a 15, which indicated her cognition was intact.*She was hospitalized from [DATE] through 7/23/25 and again from 8/7/25 through 8/22/25.*Hospice (a program for terminally ill individuals that focuses on comfort and symptom management) care was initiated on 8/23/25.*She passed away at the facility on… […]

• Actual harm, isolatedF686Sep 11, 2025

  Based on observation, interview, record review, and policy review the provider failed to identify and implement pressure ulcer (skin and/or underlying tissue injury due to prolonged pressure) preventative interventions for residents identified at risk for developing pressure ulcers for:*One of one sampled resident (31) who developed a pressure ulcer to her right heel, left upper buttocks, and left foot.*One of one sampled resident (11) who developed a pressure ulcer to his left lower and left upper buttocks.Findings include:1. Observation and interview on 9/9/25 at 9:22 a.m. […]

• Actual harm, isolatedF689Sep 11, 2025

  Based on observation, interview, record review, and policy review, the provider failed to ensure: Interventions were implemented or updated to mitigate falling incidents for one of one sampled resident (14) identified at risk for falling who fell and sustained facial bruising and to have completed and documented a thorough investigation of that fall.Findings include:1. Observation on 9/9/25 at 8:46 a.m. of resident 14 in her room revealed she was lying on her side in bed. There was purple colored bruising beneath and above her right eye, extending to her forehead hairline. The resident stated she had fallen but was not sure how that had occurred. Her bed was low to the floor. […]