Avantara Clark City

In the surveyor’s words

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

• Actual harm, isolatedF689Sep 12, 2024

  Based on interview, observation, and record review, the provider failed to ensure a bed frame was maintained and free of hazardous sharp areas for one of one sampled resident (1) who acquired a skin tear to her right lower outer ankle. Findings include: 1. Interview on 9/09/24 at 3:51 p.m. with resident 1 revealed: *She was lying in her bed and stated she had a cut on her right leg that was caused from the metal on her bed when they were putting her to bed after using the bathroom. *She stated she had no other skin concerns. 2. Record review of resident 1's skin alteration evaluations revealed: *On 8/18/24 resident 1 received a skin tear to her right outer ankle while CNA I transferred her into bed. -The skin tear measured 6.0 L X 3.0 W x 0.5 centimeters (cm) deep. […]

• No harm, potential for more than minimal, patternF689Jan 8, 2026

  Based on record review, interview, observation, document review, South Dakota Department of Health (SD DOH) facility reported incidents (FRI), and policy review, the provider failed to ensure: *An environment was free of flammable materials where two of two sampled resdients (2 and 26) were observed smoking. *Assistive devices were used for one of one 1 sampled resident (2) who used cigarette holders to prevent a burn. *Appropriate supervision for one of three sampled resident (26) while smoking. *Facility exit and interior doors functioned appropriately, and staff were re-educated as stated in the corrective actions in the 11/16/25 and 11/26/25 FRI regarding one of one closed sampled resident (37) who eloped outside and entered a room where chemicals were stored. Findings include: 1. […]

• No harm, potential for more than minimal, patternF880Jan 8, 2026

  Based on observation, interview, and policy review, the provider failed to ensure the staff followed infection control practices regarding: *Foley catheters (flexible tubing placed in the bladder to drain urine), tubing and urinary drainage bag placement for two of two sampled residents with foley catheter. *Hand hygiene by one of one registered nurse (RN) D observed administering medications to multiple residents during a noon meal service without sanitizing her hands in between each resident's medication administrations.*One of one certified nursing assistant (CNA) (F) observed without wearing a gown and gloves when transferring a resident (26) on enhanced barrier precautions (EBP), and did not clean the lift after transferring the resident. Findings include:1. […]

• No harm, potential for more than minimal, patternF657Jun 15, 2023

  Based on record review, interview and policy review the provider failed to ensure the 48 hour nutritional care plans for two of four sampled residents (11 and 22) were updated in their comprehensive care plan. Findings include: 1. Review of resident 11's medical record revealed he: *Was admitted on [DATE]. *Had diagnoses that included: Anemia secondary to blood loss, type 2 diabetes mellitus with hyperglycemia and pneumonitis due to inhalation of other solids and liquids. *Was on a consistent carbohydrate (CCHO) diet. […]

• No harm, potential for more than minimal, patternF700Jun 15, 2023

  Based on observation, interview and record review the provider failed to ensure quarterly side rail assessments were completed for three of seven residents (4, 5, and 19). 1.Observation on 6/14/23 at 9:00 a.m. of resident 5's room revealed she had a one-half side rail on the left side of her bed. Interview on 6/14/23 at 9:30 a.m. with maintenance director E revealed: *He stated the assessments had been completed in the four months since he began working at this facility. *He provided documentation of a side rail audit with one bed rail audit conducted on 5/30/23 for room [ROOM NUMBER] which was not resident 5's room. *He admitted that he had not done as many assessments as he thought. Interview on 6/14/23 at 3:34 p.m. […]