Cycle 1
Health 2025-03-20 · Fire 2025-03-20
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Lake Norden, SD
Avantara Lake Norden
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
803 Park Street, Lake Norden, SD
(605) 785-3654
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
48
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Legacy Healthcare
Operator or chain grouping
Approved since
1991-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
90 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.78
Registered nurse staffing · state 0.80 · national 0.68
LPN hours / resident day
0.33
Licensed practical nurse staffing · state 0.49 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.61 · national 2.35
Total nurse hours
3.21
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.11
RN + LPN hours · state 1.28 · national 1.54
Weekend hours
2.84
Weekend nurse staffing · state 3.32 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.84
CMS adjusted RN staffing hours
Adjusted total hours
3.47
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,028
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.97
Composite VBP score used to determine payment impact.
Payment multiplier
0.9836
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.63
Baseline 46.51% · Performance 48.84% · Measure score 3.63 · Achievement 3.63 · Improvement 0
Adjusted total nurse staffing
1.36
Baseline 3.85 hours · Performance 3.47 hours · Measure score 1.36 · Achievement 1.36 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.96% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 34 · Observed rate 11.76% · Lower 95% interval 7.28% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 93.55% |
95.27%
1.7 pts worse
|
Numerator 29 · Denominator 31 |
| Falls with major injury | 3.23% |
0.77%
2.5 pts worse
|
Numerator 1 · Denominator 31 |
| Discharge self-care score | 29.17% |
53.69%
24.5 pts worse
|
Numerator 7 · Denominator 24 |
| Discharge mobility score | 25% |
50.94%
25.9 pts worse
|
Numerator 6 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 6.45% |
2.29%
4.2 pts worse
|
Numerator 2 · Denominator 31 · Adjusted rate 6.66% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 2.9% |
8.2%
5.3 pts worse
|
Numerator 2 · Denominator 69 |
| Staff flu vaccination coverage | 35.25% |
42%
6.8 pts worse
|
Numerator 49 · Denominator 139 |
| Discharge function score | 41.67% |
56.45%
14.8 pts worse
|
Numerator 10 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.5
0.8 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.9
1.6 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.3 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
95.4%
4 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.6% |
96.9%
0.7 pts better
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
5.1%
1.5 pts better
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 2.7% · Q3 2.3% · Q4 4.3% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.4% |
4.6%
6.8 pts worse
|
11.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 17.5% · Q4 25.0% · 4Q avg 11.4% |
| Percentage of long-stay residents who lose too much weight | 2.0% |
5.5%
3.5 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 2.4% · Q4 2.4% · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.6% |
17.8%
8.8 pts worse
|
19.6%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 20.6% · Q3 28.6% · Q4 31.8% · 4Q avg 26.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.7% |
25.1%
5.4 pts better
|
16.7%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 19.2% · Q3 18.9% · Q4 16.2% · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.7% |
21.3%
3.4 pts worse
|
16.3%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 49.6% · Q2 27.9% · Q3 7.1% · Q4 13.4% · 4Q avg 24.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.0% |
21.6%
7.4 pts worse
|
14.9%
14.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 20.6% · Q3 39.0% · Q4 29.5% · 4Q avg 29.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
2.0%
0.1 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 3.0% · Q3 2.2% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
3.3%
2.7 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.3% |
25.8%
5.5 pts worse
|
19.8%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.7% · Q2 34.1% · Q3 29.0% · Q4 30.1% · 4Q avg 31.3% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
4.6%
2 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.8% · Q3 3.4% · Q4 2.4% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
83.2%
13.6 pts better
|
81.7%
15.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.0% · Q2 93.5% · Q3 100.0% · 4Q avg 96.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.4% |
11.7%
3.3 pts better
|
12.0%
3.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.4% · Observed 8.7% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.7%
1.7 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.0% |
78.2%
18.8 pts better
|
79.7%
17.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 9.7% |
21.5%
11.8 pts better
|
23.9%
14.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.7% · Observed 8.7% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-16 · Fire 2023-11-16
2 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-01-19 · Fire 2023-01-19
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-03-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-30
C · Minimal harm
2023-11-16
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-12-31
E · Potential for more than minimal harm
2023-01-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-06
C · Minimal harm
2023-01-19
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-02-03
C · Minimal harm
2023-01-19
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2023-01-19
Inspection history
Recent health citations
B · Minimal harm
2025-03-20
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-04-25
E · Potential for more than minimal harm
2023-11-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-28
D · Potential for more than minimal harm
2023-11-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-12-28
G · Actual harm
2023-01-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-14
Penalties and ownership
What sits behind the stars
Ownership
Chaim Rajchenbach Descendants Tr Ua 04282008
5% Or Greater Direct Ownership Interest · Organization
Doros Generation Trust U/A/D 1/3/12
5% Or Greater Direct Ownership Interest · Organization
Oakway Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Devine, William
Operational/Managerial Control · Individual
Grimm, Margaret
Operational/Managerial Control · Individual
Lake Norden Sd Property Holdings, LLC
5% Or Greater Security Interest · Organization
Rajchenbach, Chaim
Operational/Managerial Control · Individual
Shabat, Menachem
Operational/Managerial Control · Individual
Truist Bank
Operational/Managerial Control · Organization
Truist Bank
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
#1
Estelline Nursing and Care Center
Estelline, SD
4-star overall rating with 3-star inspections with $16,826 in total fines
#2
Good Samaritan Society De Smet
De Smet, SD
2-star overall rating with 2-star inspections with $10,647 in total fines with 11 recent health deficiencies
#3
Jenkin's Living Center
Watertown, SD
1-star overall rating with 1-star inspections with $53,086 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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