Avantara Saint Cloud
302 St Cloud Street, Rapid City, SD 57701 · Pennington County · 78 certified beds · avg 72 residents/day · certified since May 1, 1991
Abuse citation flag (CMS)
Part of chain: LEGACY HEALTHCARE (89 facilities, chain avg rating 2.9★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Mar 18, 2026 · F-0580 · triggered by a complaint
The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Why it matters: A family could learn about a serious injury or decline days later, after the chance to act has passed.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 14, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 13, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 5, 2025 (Past Non-Compliance)
▲ Actual harm, one-off · Oct 26, 2023 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 22, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (17)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 18, 2026 | ▲ G · Actual harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Mar 18, 2026 | D · Potential for harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint |
| Jan 27, 2026 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jan 27, 2026 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 27, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Aug 13, 2025 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jul 2, 2025 | E · Potential for harm, repeated | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · from a complaint |
| Mar 27, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Nov 7, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Nov 7, 2024 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Nov 7, 2024 | E · Potential for harm, repeated | The facility did not keep residents' personal and medical information private and confidential. |
| Nov 7, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Nov 7, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Nov 7, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Oct 26, 2023 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Oct 26, 2023 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Oct 26, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD). |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (6 → 3).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 3 | 1 | G ▲ |
| 2024 | 6 | 0 | F |
| 2025 | 3 | 1 | G ▲ |
| 2026 | 5 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $24,751.
| Date | Type | Amount / length |
|---|---|---|
| Aug 13, 2025 | Fine | $13,343 |
| Oct 26, 2023 | Fine | $11,408 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | South Dakota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.97 | 4.32 | 3.95 | bottom 3% in South Dakota; bottom 13% in the U.S. |
| Registered Nurse hours | 0.49 | 0.91 | 0.69 | bottom 3% in South Dakota; bottom 37% in the U.S. |
| Weekend total nurse staffing | 2.71 | 3.71 | 3.50 | bottom 9% in South Dakota; bottom 17% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.37 | 0.51 | 0.48 | bottom 29% in South Dakota; bottom 46% in the U.S. |
| Total nursing staff turnover (%) | 57.3 | 48.2 | 45.8 | bottom 22% in South Dakota; bottom 21% in the U.S. |
| RN turnover (%) | 77.8 | 34.7 | 42.9 | bottom 4% in South Dakota; bottom 7% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.12, RN 0.52, weekend 2.85. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Doros Generation Trust U/A/D 1/3/12 | Organization | 5% or Greater Direct Ownership Interest | 43% | 07/01/2019 |
| GPN Family Trust U/A/D 4/28/08 | Organization | 5% or Greater Direct Ownership Interest | 43% | 07/01/2019 |
| Oakway Operations LLC | Organization | 5% or Greater Direct Ownership Interest | 15% | 07/01/2019 |
| Altena, Ashaley | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/08/2023 |
| Altena, Ashaley | Individual | ADP of the SNF | NOT APPLICABLE | 10/08/2023 |
| Doros Generation Trust U/A/D 1/3/12 | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| GPN Family Trust U/A/D 4/28/08 | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| Legacy Healthcare Financial Services LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| Ptacek, Travis | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
| Ptacek, Travis | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| Rajchenbach, Chaim | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2019 |
| Rajchenbach, Chaim | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2019 |
| Rajchenbach, Chaim | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| RSM Us LLP | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Saint Cloud SD Property Holdings, LLC | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 07/01/2019 |
| Saint Cloud SD Property Holdings, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| Shabat, Menachem | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2019 |
| Shabat, Menachem | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2019 |
| Shabat, Menachem | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| Truist Bank | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 04/01/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "Where do you post your daily staffing numbers, and can I see today's?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Avantara Mountain View | 1.1 mi | Rapid City, SD | ★★☆☆☆ | 2/5 | |
| Westhills Village Health Care Facility | 1.6 mi | Rapid City, SD | ★★★★★ | 4/5 | |
| Avantara North | 2.0 mi | Rapid City, SD | ★★★☆☆ | 3/5 | |
| Avantara Arrowhead | 2.1 mi | Rapid City, SD | ★☆☆☆☆ | 1/5 | abuse |
| Fountain Springs Healthcare | 2.5 mi | Rapid City, SD | ★★★☆☆ | 3/5 | |
| Clarkson Health Care | 2.6 mi | Rapid City, SD | ★★★★★ | 4/5 | |
| Good Samaritan Society - St Martin Village | 4.2 mi | Rapid City, SD | ★★☆☆☆ | 2/5 | |
| Good Samaritan Society New Underwood | 19.9 mi | New Underwood, SD | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
All facilities in Rapid City →
Facility data as of CMS processing date 2026-08-01. CCN 435060.