Avantara Saint Cloud

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 physician orders for an antibiotic, a medicated nebulizer (a device that converts liquid medication into an inhalable mist) treatment, and cough syrup were transcribed and initiated by one of one registered nurse (RN) F which resulted in a delay of treatment for one of one sampled resident 2, which potentially contributed to his transfer to the emergency room (ER). This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident.Findings include:1. Review of the provider's 3/4/26 submitted SD DOH FRI report regarding resident 2 revealed that on 3/3/26, RN F reported that resident 2 was experiencing symptoms of cough and congestion to physician assistant-certified (PA-C) D. PA-C D then saw (evaluated) resident 2 at the facility. PA-C D reported to RN F and the director of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and policy review, the provider failed to ensure medications and biologicals were labeled, stored, and discarded regarding:*Expired medications and supplies were discarded in two of two observed storage rooms.*One of one medication cart that was left unattended and unlocked by one of one registered nurse (RN) (I) in the dining room, where residents, unauthorized staff, and visitors could access it. *Medications with shortened expiration dates (medications that expire in a timeframe after opening that is prior to the manufacturer's expiration date) stored in one of one medication carts were labeled when they were opened. Findings include:1. Observation on 1/26/26 at 1:52 p.m. in the main storage room revealed: *One box of a three-layer compression bandage system [bandages layered to provide sustained and cushioned compression for treating venous issues such as leg wounds with swelling) that expired on 9/6/24. *One box of Optifoam AG Nonadhesive Dressing with Antibacterial Silver (non-stick dressing infused with silver to act as an antibacterial agent)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and policy review, the provider failed to ensure: *One of one observed certified nursing assistant (F) who assisted three of three sampled residents (62, 56, and 22) with eating during one of one observed noon meal service. *One of one observed licensced practical nurse (E) who assisted two of two sampled residents (1 and 38) with eating during one of one noon meal service. Findings include: 1. Observation on 1/25/26 at 11:53 a.m. in the main dining room during the noon meal revealed: *Resident 62, 56, and 22 sat at the same dining table (table 6). *Certified nursing assistant (CNA) F helped resident 62 apply a clothing protector, moved her wheelchair closer to the dining room table, and locked resident 62's wheels. *Without washing or sanitizing her hands, CNA F went to the serving counter and picked up two meal plates and served them to the residents. She returned to the serving counter and used an alcohol-based hand rub (ABHR) to sanitize her hands. She picked up two meal plates and served them to two other residents. *CNA F then…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure staff followed professional standards of practice regarding the respiratory care for one of one sampled resident (78), who received oxygen when he previously resided at a hospital from [DATE] through his admission to the provider's facility on 1/21/26, when staff failed to clarify and provide the resident's oxygen needs. Findings include:1. Observation and interview on 1/25/2026 at 1:49 p.m. with resident 78 in his room revealed:*He was sitting in his recliner chair with an oxygen concentrator machine (a device that filters room air into purified oxygen) stored between the chair and his bed. *There was a plastic storage bag attached to the oxygen concentrator machine, which had 1/26/26 and initials handwritten on it in black ink.*An unopened package of Procure brand seven-foot nasal cannula (a flexible tube with two prongs inserted into the nostrils to deliver oxygen) was sitting on his bedside table. *He thought he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on South Dakota Department of Health (SD DOH) complaint intake, interview, report review, facility assessment review, and policy review, the provider failed to ensure daily posted staffing information was updated to reflect the actual number of nursing staff and the hours those staff had worked on three of four overnight shifts reviewed. Findings include: 1. Review of the 6/23/25 SD DOH complaint intake report revealed the complainant was concerned there is not enough staff to care for the residents. The complainant wished to have their identity protected. 2. Interview on 7/3/25 at 9:20 a.m. with the complainant revealed: *The complainant had assumed the overnight shift was short-staffed because there were constant [job] postings for that shift. -The complainant was not able to provide specific dates or times when it was thought the overnight shift had been short-staffed. 3. Review of the provider's 6/25/25 facility assessment revealed one to two licensed nurses were needed during the overnight shift to ensure the needs of the residents had been met. Three to four CNAs were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, record review, observation, and interview, the provider failed to protect the residents' right to be free from physical abuse for two of two sampled cognitively impaired residents (1 and 2) by one of one certified nursing assistant (CNA) (C). This citation is considered past non?compliance based on a review of the corrective actions the provider implemented immediately following the incident. Findings include: 1. Review of the provider's 1/2/25 SD DOH FRI revealed: *On 1/2/25, dementia champion E reported CNA C forcibly grabs her [resident 1] arms back and forces her [resident 1] down to the chair, forces her [resident 1] to bend her [resident 1] knees, and she [resident 1] started crying. *CNA C was suspended immediately, pending investigation. *A full investigation was initiated that included staff interviews, video surveillance, and immediate notification to administrator/abuse coordinator A. *After the investigation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 11/4/24 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. -Twelve of 20 unfilled cups on one of two trays had white-colored build-up on their bottoms and/or their insides. Scratch-like marks on the insides resembled scrub brush marks. *FSM E stated the cup discoloration was lime build-up and commented to cook P Are you the only one who knows how to use a brush? *One side of the dual plate warmer near the serving area held regular plates…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. revealed a strong urine odor was again present upon entrance into the secured unit described above. *A soiled utility room was located directly across the hall from the entrance into the secured unit. -That room had soiled linen and garbage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, South Dakota (SD) State Long-Term Care Ombudsman Program handbook review, and policy review, the provider failed to ensure: *Window coverings in 12 of 14 resident rooms (301, 302, 303, 304, 305, 306, 307, 309, 311, 312, 314, and 316) located in the 300 Hall had protected those residents' right to privacy. *Window coverings in 5 of 9 resident rooms (105, 107, 111, 113, and 115) located in the 100 hall had protected those residents' right to privacy. *One of 14 residents' (2) electronic medical records (EMR) were secured and not accessible to other residents, staff, or the public. *One of two medication carts were locked and medications were not accessible to other residents, staff, and the public by one of one registered nurse (RN) J in the Main dining room during the noon medication pass. Findings include: 1. Observation on 11/4/24 at 7:15 p.m. on the sidewalk leading to the main entrance of the facility revealed: *Resident rooms on the north side of the 300 hallway ran parallel to that sidewalk. -The windows in those rooms faced the visitor's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, the provider failed to maintain a clean and homelike environment for: *8 of 14 resident rooms (301, 303, 304, 309, 311, 312, 314, and 316) on the 300 hallway. *5 of 22 resident rooms (202, 204, 206, 207 and 209) on the 200 hallway. *6 of 23 resident rooms (103, 104, 108, 110, 115, and 117) on the 100 hallway. Findings include: 1. Random observations on 11/5/24 between 9:30 a.m. and 3:35 p.m. inside the rooms on the 300 hallway revealed: *room [ROOM NUMBER] had areas of exposed sheetrock near the foot and head of the bed, and behind the headboard of that bed which was positioned along the wall beneath the window. -There was an area of exposed sheetrock near the head of another bed that was positioned along the wall near the doorway of that room. *In room [ROOM NUMBER], the recliner's headrest was worn and no longer a cleanable surface. *room [ROOM NUMBER]: There was an area approximately 12 inches by 12 inches on the wall beneath the window near the foot of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, policy review, and South Dakota (SD) State Long-Term Care Ombudsman Program handbook review, the provider failed to ensure: *One of one sampled resident (31) had received diabetic fingernail care to maintain a dignified appearance. *One of one sampled resident (8) was dressed in a dignified manner. Findings include: 1. Observation and interview on 11/5/24 at 9:26 a.m. with resident 31 while she rested in her bed revealed: *She was chewing and sucking on her left index and middle finger and stated she was hungry. *Inspection of both hands revealed she had long, uneven, fingernails that extended approximately one-fourth of an inch beyond her finger pads. -There was a dark brown build-up of an unknown substance caked under each fingernail that extended outwards from the edge of each finger pad to the middle of each fingernail. *An odor of feces was detected at her bedside. Observation and interview on 11/6/24 at 9:40 a.m. with the assistant director of nursing (ADON) C and contracted hospice registered nurse (RN) L during resident 31's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and job description review, the provider failed to ensure physician's orders were followed for the use of: *TED Hose (thromboembolic deterrent compression stockings used by non-ambulatory residents) by one of one sampled resident (39). *Redi-Wraps (adjustable compression wrap) by one of one sampled resident (8). *Gradual compression stockings (compression stockings that are tightest around the ankle and gradually loosen up the leg) by one of one sampled resident (65). Findings include: 1. Observation and interview on 11/4/24 at 2:26 p.m. with resident 39 in her room revealed: *She was sitting in her recliner with the leg rests elevated. -On the wall behind her recliner was a sign that read Ted Hose on in AM and off in PM. *The resident was wearing regular socks on her feet. -She had no TED Hose that fit her and had not worn TED Hose since the summer. Observations on 11/5/24 at 9:11 a.m. and again on 11/6/24 at 9:41 a.m. of resident 39 in her room revealed she was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of the South Dakota Board of Nursing website, and policy review, the provider failed to ensure professional standards of care were followed for: *Medication administration practices by one of one licensed practical nurse (LPN) (H) for three of three observed residents (2, 7, 17, and 22). *Ensuring physician's orders for Tylenol were written for two-325 miligram (mg) tablets for three of three sampled residents (8, 33, and 65) to eliminate the need for a dose calculation by one of one unlicensed medication aide (UMA) (I). *Insulin administration by one of one LPN (F) for one of one sampled resident (25). *deceased note was documented in the medical record of one of one sample resident (71). *A follow-up appintment was made for one of one sampled resident (49) to receive a new lower partial denture. Findings include: 1. Observation and interview on [DATE] at 11:20 a.m. with LPN H in the 300 hallway revealed: *In one of her opened medication (med) cart drawers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and policy review the provider failed to assess, document and provide interventions per their policy for one of one sampled resident (49) who had suicidal ideations. 1. Observation and interview on 10/24/23 at 2:42 p.m. with resident 49 revealed: *His door was closed. *CNA J knocked on resident 49's door. -Resident 49 opened the door and came into the hallway. *Resident 49 was smiling and answered basic questions before returning to his room. Interview on 10/24/23 at 2:50 p.m. with CNA J revealed resident 49 often barricaded his door from the inside. Review of resident 49's medical record revealed: *He was admitted on [DATE]. *His diagnoses included: -Post-Traumatic Stress Disorder. -Alcohol-induced persisting dementia. -Alzheimer's Disease. -Anxiety. -Obstructive sleep apnea. -Hearing loss. *His 9/22/23 Brief Interview of Mental Status score was 5, indicating he had severe cognitive impairment. *A 9/22/23 nurse's progress note revealed: -His speech was clear. -He…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.