Avantara Saint Cloud
Rapid City, South Dakota · CCN 435060
21 surveys since 2011, 11 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
- 89
- Surveys
- 21
- Harm or worse
- 11
- 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
- 78
- Ownership
- For profit - Limited Liability company
- Chain
- LEGACY HEALTHCARE
- County
- Pennington
- Medicare-certified since
- 1991
CMS ratings
- Overall
- 2
- Health inspection
- 3
- Staffing
- 1
- 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 19 facilities of 66–99 beds in South Dakota.
Last survey on record
Mar 18, 2026
236 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 | 3.12 | 3.70 |
| Registered-nurse hours per resident day | 0.52 | — |
| Annual nurse turnover | 57.3% | 46.6% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $39,131 across 3 penalties
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 | G317.6% | H— | I— |
| No harm, potential for more than minimal | D635.3% | E635.3% | F211.8% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6002×
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- F8802×
Provide and implement an infection prevention and control program.
- F5501×
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- F5801×
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- F5831×
Keep residents' personal and medical records private and confidential.
In the surveyor’s words
From the most serious findings on record at Avantara Saint Cloud, in the surveyor’s own words.
- Actual harm, isolatedF580Mar 18, 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 that the physician was promptly notified of a change in condition for review and recommendations to ensure prompt assessment and treatment for one of one sampled resident (1) identified to be vomiting and with increased weakness, by one of one registered nurse (RN) E. This failure resulted in resident 1 being transferred to the emergency room (ER) for evaluation and subsequent hospitalization. The provider also failed to notify the resident's first emergency contact of the resident's change in condition. Findings include:1. […]
- Actual harm, isolatedF600Aug 13, 2025
Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, and interview, the facility failed to protect the resident's right to be free from neglect by having failed to ensure the safety of one of one sampled resident (1) who sustained femur (thigh bone) fractures after being transferred from her wheelchair to her bed by two of two certified nursing assistants (D and E) who did not follow her care plan or the facility's policy for gait belt (a waist strap gripped as support for safe mobility and transfers) use; and by one of one licensed practical nurse (LPN) C who did not perform a physical assessment of resident 1 after being notified by CNA D and CNA E of the transfer. […]
- Actual harm, isolatedF686Oct 26, 2023
Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (19) who had a history of moisture-associated skin damage (MASD) and had a current pressure ulcer (PU) had physician-ordered interventions implemented to promote healing. Findings include: 1. Observations of resident 19 revealed: *On 10/24/23 at 10:00 a.m. she laid on her left side in bed with a pillow positioned behind her back to help her maintain that position. -The mattress on her bed was blue. *On 10/25/23 at 4:45 p.m. […]
- No harm, potential for more than minimal, widespreadF812Nov 7, 2024
Based on observation, interview, job description review, and policy review, the provider failed to ensure: *The kitchen and dishroom were maintained in a clean and functional manner. *Food items placed on trays and delivered to residents to eat in their rooms (room trays) were kept covered during transport until they were delivered to their rooms. *Insulated dinner plate covers were handled in a sanitary manner. Findings include: 1. Observation and interviews with food service manager (FSM) E, cook N, and dietary aide O on [DATE] from 5:00 p.m. through 6:40 p.m. during the initial kitchen tour and the evening meal service revealed: *Plastic drinking cups were being filled for the evening meal by cook N. […]
- No harm, potential for more than minimal, widespreadF880Nov 7, 2024
Based on observation, interview, and policy review, the provider failed to maintain the environment and resident use items in a clean and odor-free condition for: *A soiled utility room located directly across from the entrance into the secured unit. *Two of sixteen sampled resident rooms (103 and 108) located in the 100 hallway. *One of one laundry room. *One of one clean utility room located in the secured unit. *A urine-soaked chair from one of one sampled resident's (58) room. Findings include: 1. Observation during the initial tour on 11/4/24 at 12:45 p.m. revealed a strong urine odor upon entrance through the double doors that led into the secured unit of the building where the 100, 200, and 400 hallways were located. Observation on 11/5/24 at 1:48 p.m. and at 1:52 p.m. […]
Read 28 findings in full →The most serious and the most recent: 28 of 89 on record.
Every survey on record
FindingsAt actual harm or above
- Mar 18, 2026Complaint2 findings · 1 harm
- Jan 27, 2026Standard3 findings
- Aug 13, 2025Complaint1 finding · 1 harm
- Jul 2, 2025Complaint1 finding
- Mar 27, 2025Complaint1 finding
- Nov 7, 2024Standard and complaint6 findings
- Oct 26, 2023Standard3 findings · 1 harm
- Aug 31, 2022Standard6 findings
Show the 13 earlier surveys
- Nov 2, 2021Infection control1 finding
- Dec 16, 2020Infection control2 findings
- Jul 7, 2020Infection control1 finding
- Sep 19, 2019Standard14 findings · 2 harm
- Jul 11, 2018Standard1 finding
- May 17, 2017Standard2 findings
- Oct 18, 2016Complaint1 finding
- Mar 23, 2016Standard3 findings
- Aug 26, 2015Complaint2 findings
- Apr 9, 2015Standard and complaint17 findings · 4 harm
- Mar 5, 2014Standard5 findings
- Dec 7, 2011—12 findings · 2 harm
- Feb 16, 2011—5 findings
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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