Avantara Pierre
Pierre, South Dakota · CCN 435047
19 surveys since 2011, 12 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 121
- Surveys
- 19
- Harm or worse
- 12
- Immediate jeopardy
- 0
Findings where a surveyor recorded actual harm to a resident.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 65
- Ownership
- For profit - Limited Liability company
- Chain
- LEGACY HEALTHCARE
- County
- Hughes · rural
- Medicare-certified since
- 1991
CMS ratings
- Overall
- 2
- Health inspection
- 2
- Staffing
- 3
- Quality measures
- 2
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat more weighted findings than its peer group.
Weighted by harm level, against 18 for-profit facilities with fewer than 66 beds in South Dakota.
Last survey on record
Jul 1, 2026
131 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 2.81 | 3.20 |
| Registered-nurse hours per resident day | 0.60 | — |
| Annual nurse turnover | 40.5% | 43.9% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $22,048 across 1 penalty
- Abuse icon
- Flagged by CMS on Care Compare
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G48.9% | H— | I— |
| No harm, potential for more than minimal | D2453.3% | E920.0% | F817.8% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F5542×
Allow residents to self-administer drugs if determined clinically appropriate.
- F6002×
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- F6252×
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
- F6582×
Ensure services provided by the nursing facility meet professional standards of quality.
- F6862×
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
In the surveyor’s words
From the most serious findings on record at Avantara Pierre, in the surveyor’s own words.
- Actual harm, isolatedF689Jul 1, 2026
Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, observation, interview, and policy review, the provider failed to ensure the staff provided accident prevention interventions and device use according to the resident's care plans (personalized plan that addresses a resident's care needs, goals, and interventions) for one of one sampled resident (29) who needed to be transferred with the use of a full body mechanical lift (a mechanical lift and sling used to lift a person's full body) and sustained a laceration (cut or torn skin) on his right lower leg when certified nursing assistant (CNA) R and contracted travel CNA S assisted the resident to pivot-transfer (when assisted to a standing position, the resident then turns their body to move… […]
- Actual harm, isolatedF600Apr 2, 2025
Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, interview, and policy review, the provider failed to protect the resident's right to be free from neglect for one on one sampled resident (206) who expressed he felt bad that he had been sent to the emergency room (ER) by registered nurse (RN) (N) without being provided personal hygiene after he had been incontinent of loose stool. Findings include: 1. Review of the provider's 3/15/25 SD DOH FRI regarding resident 206 revealed: *He was admitted to facility on 3/13/25. *His Brief Interview for Mental Status (BIMS) assessment score was 15 which indicated he was cognitively intact. *On 3/14/25 he was transported to a local ER for evaluation by ambulance. […]
- Actual harm, isolatedF686Apr 2, 2025
Based on observation, interview, record review, and policy review, the provider failed to identify and implement pressure ulcer prevention interventions to ensure facility-acquired pressure ulcers had not developed for one of two sampled residents (205) identified at high risk for skin breakdown and dependent on the staff assistance with their activities of daily living (ADL). Findings include: 1. Observation and interview on 3/31/25 at 8:38 a.m. with resident 205 revealed: *He was seated in his wheelchair and wore blue padded pressure-reducing boots on both of his feet. *He said he had been at the facility for about two weeks and did not know why he needed to wear those boots. -He stated his feet did not hurt. 2. Observation and interview on 4/1/25 at 7:59 a.m. […]
- Actual harm, isolatedF675Jan 13, 2023
Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (52) had been: *Provided with appropriate activities to meet his sensory needs. *Free from isolation. *Cared for by staff that had been educated to meet his unique needs. Findings include: Resident 52 was admitted from a local group home on 8/18/22 and had multiple diagnoses that included Down syndrome, unspecified; autistic disorder; dysphagia, oral phase; and developmental disorder of scholastic skills, unspecified. Observation on 1/10/23 at 8:00 a.m. […]
- No harm, potential for more than minimal, widespreadF847Apr 2, 2025
Based on observation, interview, record review, Voluntary Agreement for Arbitration review, and policy review, the provider failed to ensure 50 of 55 residents (1, 2, 3, 4, 5, 7, 10, 12, 13, 15, 16, 19, 20, 21, 22, 24, 25, 26, 27, 28, 29, 30, 31, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 46, 47, 48, 50, 104, 105, 106, 115, 154, 156, 204, 205, 206, 304, 305) who had entered into an Arbitration Agreement upon admission to the facility were explicitly granted the right to rescind the agreement within 30 calendar days of signing it. Findings include: 1. Observation and interview on 3/31/25 at 1:25 p.m. […]
Read 29 findings in full →The most serious and the most recent: 29 of 121 on record.
Every survey on record
FindingsAt actual harm or above
- Aug 6, 2026Complaint1 finding
- Jul 1, 2026Standard and complaint12 findings · 1 harm
- May 7, 2025Complaint1 finding
- Apr 2, 2025Standard and complaint9 findings · 2 harm
- Jan 9, 2024Standard and complaint14 findings
- Jun 16, 2023Complaint2 findings
- Jan 13, 2023Standard9 findings · 1 harm
- Aug 17, 2021Standard10 findings
Show the 11 earlier surveys
- Apr 22, 2021Infection control1 finding
- Feb 18, 2021Complaint1 finding
- Jul 10, 2019Standard and complaint20 findings · 3 harm
- Apr 12, 2018Standard2 findings
- Feb 23, 2017Standard1 finding
- Feb 3, 2016Standard2 findings
- May 7, 2015Complaint5 findings
- Feb 11, 2015Standard5 findings
- Dec 18, 2013—4 findings
- Jan 10, 2013Standard14 findings · 3 harm
- Oct 19, 2011—8 findings · 2 harm
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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