Avantara Lake Norden

In the surveyor’s words

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

• Immediate jeopardy, isolatedF803Feb 19, 2026

  Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to ensure a physician orders for a therapeutic pureed (blended food) diet was followed for one of one sampled resident (1) who had a diagnosis of dysphagia (difficulty swallowing) and received a snack from one of one certified nursing assistant (CNA) (D) that was not the right texture and then required life-saving measures through use of the Heimlich maneuver after the food became lodged in his throat. On 2/18/26 at 12:59 p.m., an Immediate Jeopardy was identified for a facility reported incident (FRI) related to the quality of care and treatment that occurred on 2/11/26 at 12:59 a.m. […]

• Actual harm, isolatedF686Jan 19, 2023

  Based on observation, interview, record review, and policy review, the provider failed to put appropriate interventions in place for one of two sampled resident (289) to prevent a pressure ulcer from developing. Findings include: 1. Observation and interview on 1/18/23 at 11:49 a.m. revealed resident 289: *Was sitting in a recliner in his room with his legs elevated and a heel boot on his left foot. *Stated he had a wound on his heel. *Reported displeasure that it had developed since he moved into the nursing home. 2. Observation on 1/18/23 at 3:49 p.m. […]

• No harm, potential for more than minimal, patternF760Feb 19, 2026

  Based on South Dakota Department of Health (SD DOH) facility-reported (FRI), observation, interview, record review, and policy review, the provider failed to ensure: Ten of forty-six sampled residents (3,4,5,6,7,8,10,11, and 13) had received their hour of sleep (HS) medications and Two of forty -six sampled residents (9 and 12) had recived the morning medicatons per physicians orders by one of of one licensed vocational nurse (LVN) J. *One of one LVN J had folowed physcian orders and applied a pain patch at the correct dosage for one one resident (2). Findings include:1. Review of the providers 9/9/25 SD DOH FRI involving residents (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13) revealed:*On 9/9/25 at 7:30 a.m., a resident reported she had received her medications that morning. […]

• No harm, potential for more than minimal, patternF880Nov 16, 2023

  Based on observation, interview, and policy review the provider failed to ensure necessary infection control practices in one of two shower rooms that included: *Maintenance of a plastic three drawer towel and washcloth storage bin. *An appropriate and sanitary process for the removal of and transport of bowel movement(s) occurring during showering. *Appropriate care and maintenance of a multi-resident use foot soak basin. *Appropriately individualized resident identified personal hygiene products. Findings include: 1. Observation and interview on 11/15/23 at 2:35 p.m. with certified nursing assistant (CNA) E regarding cleaning the shower room revealed: *The shower room was in the south hallway and was used by all residents except for those residents who resided in the memory care unit. […]

• No harm, potential for more than minimal, patternF655Jun 16, 2021

  Based on record review, interview, and policy review, the provider failed to ensure: *Seven of twelve (4, 6, 10, 21, 36, 93, and 142) sampled residents had received a copy of their baseline care plan. *Two of twelve (36 and 142) sampled residents had participated in a review of their baseline care plan. *Four of twelve (4, 10, 21, and 142) baseline care plans had been reviewed with the resident and/or representative within forty-eight hours. Findings include: 1. Review of resident 4's medical record revealed: *She had been admitted on [DATE]. *A multi-disciplinary care conference had been completed on 2/2/21 to review her baseline care plan. *There was no documentation she had been provided a copy of her baseline care plan. 2. […]