Inspection Reports for Avantara Milbank

The visit was complaint-related based on two facility-reported incidents involving residents 9 and 14 being lowered to the floor during transfers due to improper use of lifts and failure to have two staff assist as required. Resident 9's incident occurred on 1/28/25 and resident 14's on 2/22/25. Both CNAs involved were suspended and received education.

The provider failed to ensure resident safety by improper use of mechanical and non-mechanical sit-to-stand lifts as directed in residents' care plans and manufacturer's manuals, resulting in two residents being lowered to the floor. Both incidents involved certified nursing assistants not following proper procedures or care plan requirements, leading to minimal harm or potential for harm.

The facility failed to notify the State Long-Term Care Ombudsman of resident hospital transfers, did not provide bed hold notices to residents or their representatives, had delayed responses to resident call lights causing frustration, and did not maintain proper food service hygiene including improper glove use and unclean kitchen equipment.

The complaint involved resident 2's family raising concerns about improper use of mechanical lifts, short staffing, long call light wait times, COVID-19 positive resident wandering, and symptoms of black/tarry bowel movements. For resident 1, the complaint was about administration of two long-acting insulins simultaneously causing hypoglycemia and hospitalization. The facility failed to investigate grievances properly and failed to report the medication error to the state health department.

The facility failed to follow grievance policies related to resident complaints, did not report a significant medication error involving administration of two long-acting insulins to a resident resulting in hypoglycemia and hospitalization, and lacked proper communication and documentation regarding medication orders and grievance investigations. Staff education and medication administration competencies were found to be inadequate.

The complaint investigation was triggered by reports of bruising and swelling of unknown origin on resident 1's left knee, right wrist, and penis, and concerns about inadequate hydration for six residents. The investigation found failures in abuse investigation, reporting, and hydration monitoring.

The provider failed to conduct a thorough investigation to rule out abuse and neglect for one resident with bruising and swelling of unknown origin and failed to report these incidents to the South Dakota Department of Health. Additionally, the provider failed to ensure adequate fluid intake, monitoring, and interventions for six sampled residents, resulting in dehydration and hospitalization for one resident.

The facility failed to ensure that activities of daily living were performed and accurately documented for four sampled residents dependent on staff assistance. Observations and interviews revealed residents were not repositioned as required, call lights were often out of reach, and dependent residents were delayed in receiving feeding assistance.

The provider failed to honor residents' rights to dignity and privacy, develop comprehensive person-centered care plans, clarify medication orders leading to medication errors, ensure safe smoking practices resulting in resident falls, and maintain proper infection control practices in food service areas.

The facility failed to correctly post and follow contact precautions for a resident with C. diff., including improper use of personal protective equipment (PPE) by staff, inadequate cleaning practices using disinfectants ineffective against C. diff. spores, and insufficient staff education and training on infection control protocols. The director of nursing did not ensure consistent education for staff, and housekeeping was not verified to be using bleach as required for cleaning rooms of residents with C. diff.