Avantara Pierre

950 East Park Street · Pierre, SD · 57501 · 6052248628

65 certified beds For profit - Limited Liability company Chain: Legacy Healthcare

Why this verdict

  • 3 citations involved actual harm to residents.
  • Inspection results have improved across recent cycles.

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Red flags

1 abuse-related citation at the actual-harm level

Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.

Total nurse staffing below 3.0 hours per resident-day

2.89 reported hours vs the 3.48 minimum CMS's own staffing study recommends.

Score breakdown

Inspection record 30% of score 44
Serious harm & abuse 20% 72
Staffing 20% 60
Federal penalties 15% 71
Trend 10% 77
Context 5% 100

Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.

CMS ratings & staffing

Overall: 2 of 5 Inspections: 2 of 5 Staffing: 3 of 5 Quality measures: 2 of 5

Total nurse hours / resident-day2.893.48 min · 4.1 strong
RN hours / resident-day0.730.55–0.75
Weekend hours / resident-day2.44≈ weekday level
Nursing turnover / year41%median 45%
Fines (3-yr window)1 · $22,048

Inspection citations (35 in the current record)

  • Potential for harm · D May 7, 2025 · found via complaint

    Provide safe, appropriate pain management for a resident who requires such services.

    Corrected April 24, 2025 · Quality of Life and Care

  • Actual harm · G April 2, 2025

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

    Corrected May 1, 2025 · Quality of Life and Care

  • Actual harm · G April 2, 2025 · found via complaint

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    Corrected May 1, 2025 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · D April 2, 2025

    Allow residents to self-administer drugs if determined clinically appropriate.

    Corrected May 1, 2025 · Resident Rights

  • Potential for harm · E April 2, 2025

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

    Corrected May 1, 2025 · Resident Rights

  • Potential for harm · D April 2, 2025

    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.

    Corrected May 1, 2025 · Resident Rights

  • Potential for harm · E April 2, 2025

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Corrected May 1, 2025 · Resident Assessment and Care Planning

  • Potential for harm · D April 2, 2025

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Corrected May 1, 2025 · Quality of Life and Care

  • Potential for harm · F April 2, 2025

    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

    Corrected May 1, 2025 · Administration

  • Potential for harm · E April 2, 2025

    Provide and implement an infection prevention and control program.

    Corrected May 1, 2025 · Infection Control

  • Potential for harm · D January 9, 2024

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

    Corrected February 20, 2024 · Resident Rights

  • Potential for harm · D January 9, 2024

    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.

    Corrected February 20, 2024 · Resident Rights

  • Potential for harm · D January 9, 2024

    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

    Corrected February 20, 2024 · Resident Assessment and Care Planning

  • Potential for harm · D January 9, 2024

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Corrected February 20, 2024 · Quality of Life and Care

  • Potential for harm · D January 9, 2024

    Provide enough food/fluids to maintain a resident's health.

    Corrected February 20, 2024 · Quality of Life and Care

  • Potential for harm · D January 9, 2024

    Provide safe and appropriate respiratory care for a resident when needed.

    Corrected February 20, 2024 · Quality of Life and Care

  • Potential for harm · E January 9, 2024

    Post nurse staffing information every day.

    Corrected February 20, 2024 · Nursing and Physician Services

  • Potential for harm · D January 9, 2024

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

    Corrected February 20, 2024 · Pharmacy Service

  • Potential for harm · D January 9, 2024

    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

    Corrected February 20, 2024 · Nutrition and Dietary

  • Potential for harm · F January 9, 2024

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Corrected February 20, 2024 · Nutrition and Dietary

  • Potential for harm · F January 9, 2024

    Administer the facility in a manner that enables it to use its resources effectively and efficiently.

    Corrected February 20, 2024 · Administration

  • Potential for harm · F January 9, 2024

    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

    Corrected February 20, 2024 · Administration

  • Potential for harm · F January 9, 2024

    Have a plan that describes the process for conducting QAPI and QAA activities.

    Corrected February 20, 2024 · Administration

  • Potential for harm · D January 9, 2024 · found via complaint

    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

    Corrected January 4, 2024 · Quality of Life and Care

  • Potential for harm · D June 16, 2023 · found via complaint

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Corrected July 31, 2023 · Quality of Life and Care

Showing the 25 most recent. The Safety Report includes every citation with full findings.

Federal penalties

DateTypeAmount / length
April 2, 2025Fine$22,048

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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 435047 · certified since September 1, 1991. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.