Cycle 1
Health 2024-11-21 · Fire 2024-11-21
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Rapid City, SD
Westhills Village Health Care Facility
4-star overall rating with 3-star inspections with 8 recent health deficiencies
255 Texas St, Rapid City, SD
(605) 342-0255
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
44
Certified beds
Average residents
39
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1985-03-01
CMS approved date
Coverage
Medicare
Participation flags
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
1.07
Registered nurse staffing · state 0.80 · national 0.68
LPN hours / resident day
0.51
Licensed practical nurse staffing · state 0.49 · national 0.87
Aide hours / resident day
2.75
Nurse aide staffing · state 2.61 · national 2.35
Total nurse hours
4.33
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.28 · national 1.54
Weekend hours
3.56
Weekend nurse staffing · state 3.32 · national 3.43
Weekend RN hours
0.74
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.18
CMS adjusted RN staffing hours
Adjusted total hours
4.78
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,483
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.10
Composite VBP score used to determine payment impact.
Payment multiplier
0.9972
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.39
Baseline 18.30% · Performance 19.86% · Measure score 3.39 · Achievement 3.39 · Improvement 0
Healthcare-associated infections
3.44
Baseline 7.05% · Performance 6.81% · Measure score 3.44 · Achievement 3.44 · Improvement 0.67
Total nurse turnover
6.72
Baseline 80.85% · Performance 40.43% · Measure score 6.72 · Achievement 5.69 · Improvement 6.72
Adjusted total nurse staffing
4.08
Baseline 4 hours · Performance 4.24 hours · Measure score 4.08 · Achievement 4.08 · Improvement 0.87
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.85% |
10.72%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 189 · Observed rate 12.17% · Lower 95% interval 8.62% |
| Discharge to community | 60.78% |
50.57%
10.2 pts better
|
Better than the National Rate · Eligible stays 189 · Observed rate 64.02% · Lower 95% interval 54.46% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.43% |
95.27%
3.2 pts better
|
Numerator 125 · Denominator 127 |
| Falls with major injury | 1.59% |
0.77%
0.8 pts worse
|
Numerator 2 · Denominator 126 |
| Discharge self-care score | 69.9% |
53.69%
16.2 pts better
|
Numerator 72 · Denominator 103 |
| Discharge mobility score | 64.08% |
50.94%
13.1 pts better
|
Numerator 66 · Denominator 103 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 125 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.81% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 115 · Observed rate 4.35% · Lower 95% interval 4.08% |
| Staff COVID-19 vaccination coverage | 2.44% |
8.2%
5.8 pts worse
|
Numerator 3 · Denominator 123 |
| Staff flu vaccination coverage | 21.13% |
42%
20.9 pts worse
|
Numerator 41 · Denominator 194 |
| Discharge function score | 74.76% |
56.45%
18.3 pts better
|
Numerator 77 · Denominator 103 |
| Transfer of health information to provider | 95.45% |
95.95%
0.5 pts worse
|
Numerator 21 · Denominator 22 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 86 · Denominator 86 |
| Resident COVID-19 vaccinations up to date | 57.14% |
25.2%
31.9 pts better
|
Numerator 36 · Denominator 63 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.5
0.3 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.0 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
1.9
0.3 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.2 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.7% |
95.4%
11.7 pts worse
|
93.4%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 73.9% · Q2 89.3% · Q3 81.5% · Q4 88.5% · 4Q avg 83.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.8% |
96.9%
0.1 pts worse
|
95.5%
1.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
5.1%
3.2 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% · 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 | 3.3% |
5.5%
2.2 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 0.0% · Q3 4.2% · Q4 4.3% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.3% |
17.8%
12.5 pts better
|
19.6%
14.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.0% · Q3 8.3% · Q4 4.2% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.7% |
25.1%
10.4 pts better
|
16.7%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 20.0% · 4Q avg 14.7% · 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 | 16.2% |
21.3%
5.1 pts better
|
16.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.7% |
21.6%
0.9 pts better
|
14.9%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 21.7% · Q3 21.7% · Q4 17.4% · 4Q avg 20.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
2.0%
1.1 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
3.3%
2.3 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.1% |
25.8%
1.7 pts better
|
19.8%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 20.5% · Q3 28.3% · Q4 20.7% · 4Q avg 24.1% |
| Percentage of long-stay residents with pressure ulcers | 1.1% |
4.6%
3.5 pts better
|
5.1%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.5% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.0% |
83.2%
2.8 pts better
|
81.7%
4.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 83.1% · Q2 86.6% · Q3 88.1% · Q4 86.4% · 4Q avg 86.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
11.7%
1.9 pts better
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 8.7% · Expected 9.9% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.6% |
78.2%
2.6 pts worse
|
79.7%
4.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.4% |
21.5%
2.9 pts worse
|
23.9%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 18.5% · Expected 18.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-02 · Fire 2023-08-02
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-03-31 · Fire 2022-03-31
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
G · Actual harm
2025-07-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-08-06
D · Potential for more than minimal harm
2025-07-08
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 2025-08-06
F · Potential for more than minimal harm
2024-11-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-05
E · Potential for more than minimal harm
2024-11-21
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-01-05
E · Potential for more than minimal harm
2024-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-11-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-11-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-11-21
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-01-05
D · Potential for more than minimal harm
2022-03-31
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-04-18
Penalties and ownership
What sits behind the stars
Ownership
Presbyterian Retirement Village Of Rapid City, Inc.
5% Or Greater Direct Ownership Interest · Organization
Bertsch, Kelsey
Operational/Managerial Control · Individual
Bifulco, Leah
Operational/Managerial Control · Individual
Bifulco, Leah
Corporate Officer · Individual
Diamond, Kenneth
Operational/Managerial Control · Individual
Donohue, Tyler
Corporate Officer · Individual
Knoll, Andrea
Operational/Managerial Control · Individual
Petrotto, Maryann
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Avantara Saint Cloud
Rapid City, SD
1-star overall rating with 2-star inspections with abuse icon flag with $11,408 in total fines with 6 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
Avantara Arrowhead
Rapid City, SD
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $40,014 in total fines with 28 recent health deficiencies
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