RAPID CITY, SD - Federal health inspectors cited Avantara Arrowhead nursing home after a complaint investigation revealed a severely cognitively impaired resident received no baths for nearly three weeks after admission and went through extended periods without bathing as a spreading skin rash went inadequately treated for weeks.
The South Dakota Department of Health completed its complaint survey on March 26, 2025, citing the facility at 2500 Arrowhead Drive under F-tag 0684 for failing to provide appropriate treatment and care.
Resident Admitted in December, No Bath Until January
According to the inspection report, the resident — a male with diagnoses including sepsis, urinary tract infection, COPD, dementia, and diabetes — was admitted to Avantara Arrowhead in December 2024. His Brief Interview for Mental Status (BIMS) score was 2 out of 15, indicating severe cognitive impairment and an inability to advocate for his own care needs.
A review of bath records revealed the resident received zero baths from his mid-December admission through the end of that month. In January 2025, he received only four baths total, with a two-week gap between them. In February 2025, he received just one bath before being discharged to an assisted living center on February 3.
A bath aide told investigators she was unsure why the resident was not bathed after admission, speculating that staff may have simply forgotten to add his name to the bath schedule. This points to a fundamental breakdown in the facility's intake and hygiene tracking processes.
Skin Rash Spread for Weeks Before Treatment Was Ordered
While the resident went without adequate bathing, a skin rash developed and progressively worsened. Nursing notes documented the timeline:
- January 13, 2025: Staff noted a red, scabby rash on the resident's upper left arm and a scab on his face that he had picked open, causing bleeding. - January 20, 2025: The rash had spread to "numerous scabbing" areas across both arms from shoulders to hands, with scratch marks on both hips and abrasions on his left leg. - January 27, 2025: Scabs were documented on his upper arms, chest, and back.
Despite staff first documenting the rash on January 13, a physician order for treatment was not obtained until January 27 — a 14-day delay. Records show a registered nurse requested anti-itch cream from the physician on January 22, but the physician never responded. It took a second request from the unit manager five days later before a physician's assistant finally provided a verbal order for topical ointment.
The ointment treatment did not begin until January 28, 2025 — more than two weeks after the rash was first documented.
Why Bathing and Prompt Treatment Matter
For residents with severe cognitive impairment, regular bathing is not merely a matter of comfort — it is a medical necessity. Infrequent bathing allows skin irritants, bacteria, and fungi to accumulate, increasing the risk of dermatitis, secondary skin infections, and breakdown. A resident with diabetes, as in this case, faces heightened infection risk because elevated blood sugar impairs wound healing and immune response.
When a cognitively impaired resident develops a rash and begins scratching, the cycle of skin damage accelerates quickly. Open wounds from scratching create entry points for bacteria, potentially leading to cellulitis or sepsis — a condition this resident had already been diagnosed with previously. Standard nursing practice calls for same-day physician notification when a new skin condition is identified, with treatment orders obtained within 24 to 48 hours at most.
The two-week delay in this case, compounded by a physician who failed to respond to an electronic order request, left a vulnerable resident without relief as his condition visibly deteriorated.
Facility Acknowledged Problems
During the investigation, administrator A confirmed the facility was aware of problems with the bathing schedule. She told inspectors the issue had been discussed in the facility's Quality Assurance and Performance Improvement (QAPI) meetings, and a performance improvement project had been opened in January 2025.
Both the bath aide and an agency CNA confirmed to investigators that they had personally observed the resident's skin condition worsen over time. The agency CNA stated the scabbing from scratching had visibly progressed from her first encounter with the resident to her last interactions before his discharge.
The facility's own Skin and Pressure Injury Prevention Program policy requires that changes in a resident's condition be "recognized, evaluated and reported to the physician" in a timely manner. Its bathing policy requires documentation of bathing activity or refusal — yet investigators found no refusal documentation that would explain the extended gaps.
The deficiency was determined on March 22, 2025, and the facility implemented corrective actions by March 25. Inspectors confirmed the corrections on March 26, classifying the violation as past non-compliance with minimal harm or potential for actual harm.
For full inspection details, search Avantara Arrowhead on the [CMS Care Compare](https://www.medicare.gov/care-compare/) website.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avantara Arrowhead from 2025-03-26 including all violations, facility responses, and corrective action plans.
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