Avantara Mountain View

In the surveyor’s words

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

• Actual harm, isolatedF740May 14, 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 resident received the necessary behavioral health services to treat a diagnosed serious mental illness and to identify and implement interventions and effective communication processes with other healthcare entities to mitigate the resident's risk for self-harm for one of one sampled resident (2) with diagnosed mental health illness who attempted suicide with a call light cord.Findings include:1. Review of the provider's 5/4/26 SD DOH FRI revealed on 5/4/26 at 7:15 a.m. director of nursing (DON) B was notified by registered nurse (RN) G that on 5/3/26 at approximately 3:00 a.m. […]

• Actual harm, isolatedF697May 15, 2024

  Based on the South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to ensure adequate pain management for one of one sampled resident (1) who inflicted harm to himself that required surgical treatment at a hospital. Failure to assess and provide adequate pain control may have contributed to resident 1's action of self-harm. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident. Findings include: 1. […]

• Actual harm, isolatedF686Jun 29, 2022

  Based on observation, interview, record review, and policy review, the provider failed to ensure one of four sampled residents (59) who had been identified at risk for pressure ulcers had interventions in place timely to prevent pressure ulcer development. Findings include: 1. Observation on 6/26/22 at 6:30 p.m. of resident 59 revealed he: *Was residing on the COVID-19 unit. *Was sitting in his wheelchair, and had foam boots on both feet. Observation on 6/28/22 at 4:45 p.m. of resident 59's dressing change revealed: *He was on the bed with foam boots on both feet. *He was placed on his left side, dressing changed to his right, and left buttock by wound care/unit manager D. -Wound care/unit manager D cleansed, and measured wound. […]

• No harm, potential for more than minimal, patternF602Jul 2, 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 protect the residents' right ro be free of misappropriation of property by one of one certified nurse aide (CNA)/qualified medication aide (QMA) (D) who agreed to cash one of one sampled resident's (2) scratch tickets in exchange for half of the winning money amount and who took one of one sampled discharged resident's (1) medication for her personal use. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident. Findings include:1. […]

• No harm, potential for more than minimal, patternF609May 14, 2026

  Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review, the provider failed to report incidents to the SD DOH within the required time frame, for one of one sampled resident (3) who reported to registered nurse (RN) E that his wound was caused by his bed frame, one of one sampled resident (4) who was allegedly abused by certified nursing assistant (CNA) M and was not reported until two weeks later by CNA P, one of one sampled resident (5) who was involved in a relationship with one of one licensed practical nurse (LPN) (J), and one of one sampled resident (2) who attempted suicide. Findings include:1. […]