Avantara Huron

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Mar 12, 2026

  Based on the South Dakota Department of Health (SD DOH) complaint report, interview, document review, record review, and policy review, the provider failed to protect the resident's right to be free from sexual abuse by one of one certified nursing assistant (CNA) (D) for one of two sampled resident (57) who reported she was touched in a private area without her consent. And by one of one unidentified staff member for one of two sampled resident (78) who reported she was touched in a private area without her consent. Immediate Jeopardy (IJ) at F600, severity J., began on 3/11/26 at 11:40 a.m. when resident 57 revealed in an interview that she had a concern about being touched by a staff member on 1/23/26 during the night rounds. […]

• Actual harm, isolatedF610Mar 12, 2026

  Based on the South Dakota Department of Health (SD DOH) complaint report review, interview, document review, record review, and policy review, the provider failed to ensure two of two sampled residents' with expressed feelings of emotional distress (57 and 78) allegations of sexual abuse reported to social services designee (F) regarding having been touched in their private areas without the residents' consent by one of one certified nursing assistant (CNA) (D) and an unidentified staff member were thoroughly investigated to prevent further emotional distress, further staff-to-resident sexual abuse or to mitigate the risk of sexual abuse. Findings include:1. […]

• Actual harm, isolatedF684Mar 12, 2026

  Based on the interview, record review, call light log documentation review, and policy review, the provider failed to ensure staff responded promptly to two of four sampled residents (30 and 82) who indicated they had concerns with the call lights not being answered in a timely manner. Resident 82 reported being in pain while waiting for her call light to be answered, and Resident 30 reported urinary incontinence when having to wait for her call light to be answered. Findings Include:1. Interview on 3/8/26 at 2:03 p.m. and 3/9/26 at 10:42 a.m. with resident 30 revealed she had concerns that the facility was short of staff, staff were quitting, and the facility needed to use contracted travel staff. […]

• Actual harm, isolatedF689Mar 12, 2026

  Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (7) who eloped (left the facility without staff knowledge) from the front door of the facility on 9/2/25, and one of one sampled resident (77) who fell while being transferred by certified nursing assistant (CNA) V, who did not transfer the resident as directed in the resident's care plan (personalized plan that addresses a resident's care needs, goals, and interventions). This citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incidents.Findings Include:1. […]

• Actual harm, isolatedF600Nov 14, 2024

  Based on South Dakota Department of Health (SD DOH) facility-reported incidents (FRI), observation, interview, record review, and policy review, the provider failed to protect residents from neglect by: A. CNA Z who did not provide nighttime cares for one of one sampled resident (425) who was observed the following morning in her clothing from the previous day and incontinent of bowel. Findings include: B. Certified nursing assistant (CNA) (G) who did not provide the appropriate transfer assistance as directed in the care plan for one of one sampled resident (46) who fell . Findings include: A. 1. Review of provider's SD DOH FRI for resident 425 revealed: *At approximately 8:00 a.m. on 8/4/24 resident 425 was in bed, dressed in the same clothes she had on the day before. […]