Avantara North

In the surveyor’s words

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

• Actual harm, isolatedF690Aug 7, 2025

  Based on South Dakota Department of Health (SD DOH) complaint intake review, record review, interview, and policy review, the provider failed to:Ensure there was a physician's order for one of one closed record sampled resident's (1) urinary catheter.Ensure there was a documented clinical indication for urinary catheter use by one of one closed record sampled resident (1) that included a physician's order for catheter removal when it was no longer clinically indicated.Identify and implement measures to mitigate of one of one closed record sampled resident (1) with a urinary catheter from developing a urinary tract infection.Findings include: Review of the 6/24/25 SD DOH complaint intake revealed:On 6/18/25, the provider discharged resident 1. […]

• Actual harm, isolatedF600Oct 7, 2024

  Based on South Dakota Department of Health (SD DOH) facility-reported incidents (FRI), interview, record review, and policy review, the provider failed to ensure the safety for: *One of one sampled resident (1) who staff assisted out of the building in the early afternoon hours, left the facility grounds without staff knowledge, was returned to the facility by an unknown individual, was not appropriately assessed for potential harm, and his physician was not notified timely of the incident. *One of one sampled resident (2) whose care plan was not followed by staff who were to provide her supervision while she was in her wheelchair with a safety belt around her lap. […]

• No harm, potential for more than minimal, widespreadF804Jan 14, 2025

  Based on observation, interview, and policy review, the provider failed to ensure residents' prepared food was served and distributed in a palatable manner during two of two observed meal services. Findings include: 1. Observation and interview on 1/12/25 from 5:00 p.m. through 6:00 p.m. with cook O and certified dietary manager (CDM) N in the kitchen during the evening meal service revealed: *Cook O removed pizza from the oven at 5:08 p.m., sliced it, and moved it onto a baking sheet. -The sheet was too large to fit inside the steam table well and too short to cover the well opening it was placed on. *A temperature probe was inserted into the pizza by cook O and read 132 degrees Fahrenheit (F) at 5:16 p.m. That temperature was too low CDM N returned the pizza to the oven. […]

• No harm, potential for more than minimal, widespreadF812Sep 28, 2023

  Based on observation, interview, and policy review, the provider failed to: *Maintain the cleanliness of the following kitchen equipment: -The dishwasher. -The microwave. -The reach-in ice machine. -The tabletop in which the beverage machines were located. -The flattop grill and stove backsplash. -The ovens underneath the flattop grill and stove. -The utensil drawers that were located underneath the kitchen prep table. -The convection ovens. -The reach-in beverage cooler. *Dispose of expired and visibly spoiled foods from one of two reach-in coolers in the kitchen, one of one shared resident refrigerator, one of one dry storage room, and two of two emergency food supply cabinets. *Properly cook unpasteurized eggs prior to serving to one of one sampled resident (34). Findings include: 1. […]

• No harm, potential for more than minimal, patternF695Feb 20, 2026

  Based on observation, interview, record review, and policy review, the provider failed to ensure infection control practices were followed regarding the residents' nasal cannulas being dated and stored in plastic bags when they were not in use for four of four sampled residents (1, 9, 11, and 15) who required the use of oxygen, and one of one sampled resident (11) who used a nebulizer (a device that converts liquid medication into an inhalable mist) machine that was not cleaned after each use by the nursing staff. Findings include:1. Observation and interview on 2/18/26 at 9:01 a.m. […]