Cycle 1
Health 2025-12-09 · Fire 2025-12-09
10 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Rapid City, SD
Fountain Springs Healthcare
4-star overall rating with 3-star inspections with $22,526 in total fines with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2000 Wesleyan Blvd, Rapid City, SD
(605) 343-3555
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
83
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Evergreen Healthcare Group
Operator or chain grouping
Approved since
1998-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
41 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.82
Registered nurse staffing · state 0.80 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.49 · national 0.87
Aide hours / resident day
2.47
Nurse aide staffing · state 2.61 · national 2.35
Total nurse hours
3.95
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.28 · national 1.54
Weekend hours
3.41
Weekend nurse staffing · state 3.32 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.81
CMS adjusted RN staffing hours
Adjusted total hours
3.90
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,955
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.18
Composite VBP score used to determine payment impact.
Payment multiplier
0.9837
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.50
Baseline 20.61% · Performance 19.35% · Measure score 4.50 · Achievement 4.50 · Improvement 3.03
Healthcare-associated infections
0
Baseline 6.52% · Performance 9.12% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0.75
Baseline 57.53% · Performance 60.61% · Measure score 0.75 · Achievement 0.75 · Improvement 0
Adjusted total nurse staffing
4.82
Baseline 3.27 hours · Performance 4.45 hours · Measure score 4.82 · Achievement 4.82 · Improvement 4.21
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.63% |
10.72%
2.1 pts better
|
No Different than the National Rate · Eligible stays 154 · Observed rate 5.19% · Lower 95% interval 5.68% |
| Discharge to community | 58.15% |
50.57%
7.6 pts better
|
Better than the National Rate · Eligible stays 175 · Observed rate 52.57% · Lower 95% interval 51.62% |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.77% |
95.27%
3.5 pts better
|
Numerator 161 · Denominator 163 |
| Falls with major injury | 0.61% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 163 |
| Discharge self-care score | 42.2% |
53.69%
11.5 pts worse
|
Numerator 46 · Denominator 109 |
| Discharge mobility score | 26.61% |
50.94%
24.3 pts worse
|
Numerator 29 · Denominator 109 |
| Pressure ulcers or injuries, new or worsened | 3.07% |
2.29%
0.8 pts worse
|
Numerator 5 · Denominator 163 · Adjusted rate 3.44% |
| Healthcare-associated infections requiring hospitalization | 9.12% |
7.12%
2 pts worse
|
No Different than the National Rate · Eligible stays 97 · Observed rate 11.34% · Lower 95% interval 5.72% |
| Staff COVID-19 vaccination coverage | 4.1% |
8.2%
4.1 pts worse
|
Numerator 5 · Denominator 122 |
| Staff flu vaccination coverage | 70.34% |
42%
28.3 pts better
|
Numerator 83 · Denominator 118 |
| Discharge function score | 55.05% |
56.45%
1.4 pts worse
|
Numerator 60 · Denominator 109 |
| Transfer of health information to provider | 56.6% |
95.95%
39.4 pts worse
|
Numerator 30 · Denominator 53 |
| Transfer of health information to patient | 96% |
96.28%
0.3 pts worse
|
Numerator 72 · Denominator 75 |
| Resident COVID-19 vaccinations up to date | 29.03% |
25.2%
3.8 pts better
|
Numerator 27 · Denominator 93 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.5
0.1 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.9
1.2 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
95.4%
2.7 pts better
|
93.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 98.4% · Q3 98.4% · Q4 98.4% · 4Q avg 98.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
96.9%
1.8 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
5.1%
2 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 3.1% · Q4 6.5% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.6%
4.6 pts better
|
11.4%
11.4 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 who lose too much weight | 6.6% |
5.5%
1.1 pts worse
|
5.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 3.4% · Q3 8.5% · Q4 10.3% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.7% |
17.8%
2.9 pts worse
|
19.6%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 19.7% · Q3 22.6% · Q4 19.7% · 4Q avg 20.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 30.3% |
25.1%
5.2 pts worse
|
16.7%
13.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 32.7% · Q3 34.6% · Q4 29.8% · 4Q avg 30.3% · 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 | 13.4% |
21.3%
7.9 pts better
|
16.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.4% |
21.6%
8.2 pts better
|
14.9%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 8.3% · Q3 11.7% · Q4 28.3% · 4Q avg 13.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.0%
2 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
3.3%
3.3 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.9% |
25.8%
3.1 pts worse
|
19.8%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 28.3% · Q3 28.6% · Q4 28.9% · 4Q avg 28.9% |
| Percentage of long-stay residents with pressure ulcers | 6.1% |
4.6%
1.5 pts worse
|
5.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 2.9% · Q3 5.1% · Q4 6.5% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
83.2%
15 pts better
|
81.7%
16.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 99.2% · Q3 100.0% · Q4 95.4% · 4Q avg 98.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.2% |
11.7%
2.5 pts better
|
12.0%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.2% · Observed 8.9% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.7%
0.6 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.1% · Q3 1.2% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.1% |
78.2%
17.9 pts better
|
79.7%
16.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.2% |
21.5%
4.3 pts better
|
23.9%
6.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.2% · Observed 17.9% · Expected 24.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-04 · Fire 2024-04-04
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-03-02 · Fire 2023-03-02
4 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-12-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-12-16
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-12-16
E · Potential for more than minimal harm
2025-12-09
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-12-16
E · Potential for more than minimal harm
2025-12-09
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-12-09
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-12-09
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-12-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-12-09
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-12-09
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-12-16
D · Potential for more than minimal harm
2025-12-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-07
D · Potential for more than minimal harm
2025-05-28
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-01-24
J · Immediate jeopardy
2024-08-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-24
D · Potential for more than minimal harm
2024-05-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-04-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-22
G · Actual harm
2024-01-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-26
E · Potential for more than minimal harm
2023-03-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-02
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-07
Penalties and ownership
What sits behind the stars
$16,801
2024-08-15
Fine
Fine · fine $16,801
Fine
$5,725
2024-01-02
Fine
Fine · fine $5,725
Fine
Ownership
Pacific Northwest SNF Operations Holdings (Sd) LLC
5% Or Greater Direct Ownership Interest · Organization
Ch Pacific Northwest Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Couve Financial Services LLC
Operational/Managerial Control · Organization
Couve Healthcare Consulting LLC
Operational/Managerial Control · Organization
Fountain Springs SNF Operations, LLC
Operational/Managerial Control · Organization
Harvey, Kristine
Operational/Managerial Control · Individual
Herzka, Yisroel
5% Or Greater Indirect Ownership Interest · Individual
Lowe, Leonor
Operational/Managerial Control · Individual
Pacific Northwest Opco Management LLC
Operational/Managerial Control · Organization
Pacific Northwest SNF Operations Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Perlman, Harold
Operational/Managerial Control · Individual
Phillips, Marie
Operational/Managerial Control · Individual
Ptacek, Travis
Operational/Managerial Control · Individual
South Dakota SNF Consulting LLC
Operational/Managerial Control · Organization
Spielman, Shimon
Operational/Managerial Control · Individual
Spielman, Shimon
Corporate Officer · Individual
Witzcorp Global LLC
5% Or Greater Indirect Ownership Interest · Organization
Yenowitz, Yitzchok
5% Or Greater Indirect Ownership Interest · Individual
Yenowitz, Yitzchok
Operational/Managerial Control · Individual
Yenowitz, Yitzchok
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Avantara North
Rapid City, SD
2-star overall rating with 2-star inspections with $6,168 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Avantara Mountain View
Rapid City, SD
3-star overall rating with 3-star inspections with $9,318 in total fines with 5 recent health deficiencies
#3
Good Samaritan Society - St Martin Village
Rapid City, SD
2-star overall rating with 2-star inspections with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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