Avantara Arrowhead: Wound Care Delays Harm Resident - SD
Resident 69 at Avantara Arrowhead returned from the hospital on July 23 with orders for negative pressure wound therapy on her deteriorating left lower leg wound. The wound vacuum wasn't delivered and placed until July 29.
During those six days without treatment, the resident's wound contained 4 centimeters of fluid and infection that required surgical draining. The wound had progressed to necrosis of muscle tissue.
The infection and wound care nurse confirmed an acceptable timeframe for placing a physician-ordered wound vacuum would be 24 hours. Instead, resident 69 went without the specialized treatment for nearly a week.
Staff falsely documented the wound vacuum was in place on July 25, two days after the resident returned from hospitalization. The infection and wound care nurse later admitted she was "unsure why she had documented the NPWT was in place, as it had not been delivered to the provider until 7/29/25."
The resident's condition deteriorated during her stay at Avantara Arrowhead. She experienced significant weight gain that would have required leg elevation and edema reduction, according to the infection and wound care nurse. Her wheelchair was too small for her changing body size.
The wound began as a vascular scratch on her left lower leg. Her primary physician had been providing wound care during weekly Tuesday rounds before her July 15 hospitalization.
When resident 69 returned from the hospital on July 23, the physician ordered the negative pressure wound therapy on July 24. The device wasn't received and placed until July 29, leaving her with only wet-to-dry dressing changes during the interim.
The surgical wound on her lower left leg required opening and draining of 4 centimeters of fluid and infection. IV medication was started immediately after the surgical intervention.
Staff documentation problems extended beyond the false wound vacuum entries. The infection and wound care nurse admitted her wound measurements from July 29 were wrong. She stated the measurements documented on August 5 were the actual measurements that should have been recorded on July 29, acknowledging the error was due to surgical intervention that occurred before July 29.
The facility's regional nurse consultant revealed the provider had no policy regarding negative pressure wound therapy use for residents with physician orders. The provider completed competency training for all nurses on wound vacuum therapy only after the incident.
Staff also lacked proper training for IV medication administration. The resident's IV push medication order was changed because the provider had no documented competencies for contracted travel and agency licensed practical nurses for IV push administration. The provider would only provide medications that all staff could administer.
The facility hired an outside entity to conduct competency training for all nurses for IV push medications following the incident.
No staff member had notified the infection and wound care nurse that resident 69 was refusing care, contrary to facility protocols. The nurse confirmed resident 69 had not refused care from her.
When residents refuse treatments like dressing changes or repositioning, facility policy requires documentation in the resident's treatment administration record or progress notes. No such refusal documentation existed for resident 69.
The infection and wound care nurse started working at the facility on June 30 and believed resident 69's wheelchair had been appropriately sized when she began her employment. She was unaware the wheelchair had become too small for the resident.
The facility's documentation protocols required staff to mark "Yes" for skin alterations when residents had wounds or skin problems. This system was supposed to alert care providers to existing conditions requiring attention.
The primary physician was present when the wound vacuum was finally placed on July 29, six days after the resident returned from hospitalization needing the specialized treatment.
Federal inspectors found the facility's IV push medication administration policy addressed safe delivery of small volume IV medications and required consultation with IV pharmacists as needed. The policy mandated verification of medication orders before administration.
The wound vacuum training checklist revealed specific requirements including assessing wound dimensions, pathology, presence of undermining or tunnels, and ensuring therapy maintenance for 22 out of 24 hours daily.
Despite these protocols, resident 69 experienced a six-day gap in physician-ordered treatment while recovering from hospitalization for the same wound that ultimately required surgical intervention to drain infection and fluid buildup.
The muscle tissue death and surgical drainage occurred while the resident was without the negative pressure wound therapy designed to promote healing and prevent exactly these complications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avantara Arrowhead from 2025-09-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
AVANTARA ARROWHEAD in RAPID CITY, SD was cited for violations during a health inspection on September 11, 2025.
The wound vacuum wasn't delivered and placed until July 29.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.