Avantara Groton

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to develop and implement a resident-centered baseline care plan within 48 hours of admission for four of five sampled residents (1, 3, 20, and 37) who were recently admitted .

Inspectors wroteBased on observation, interview, record review, Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025 review, the provider failed to ensure five of five sampled residents' (4, 7, 8, 19, and 37) Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessments were accurately coded for the areas of weight loss, Pre-admission Screening and Resident Review (PASRR), insulin administration, and pneumococcal (pneumonia) vaccination status.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure medications for four of four sampled residents (18, 20, 23, and 34) with physician's orders for antifungal powder were labeled and stored according to the provider's policy.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure standard infection control practices were followed by:*One of one certified nursing assistant (CNA) (L) performed hand hygiene while assisting residents during their dining experience.*One of one CNA (K) performed hand hygiene (handwashing) before putting on gloves and after removing his gloves.*One of one CNA (P) wore personal protective equipment (PPE) (such as a gown and gloves) while providing cares for a resident (4) on contact precautions (a gown and glove were to be worn anytime there was a risk of contact with a resident or objects he may have been in contact with).*Two of two CNAs (K and P) adequately cleaned and disinfected the shower room with a hospital grade disinfectant between residents' showers in two of two shower rooms.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to ensure the code status (emergent treatment a person wishes to receive if their heart or breathing would stop) for three of three sampled residents (1, 23, and 37) was currently and accurately documented in the residents' electronic medical records.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure their policy was followed for:*Medication administration documentation for four of four sampled residents (18, 20, 23, and 34) with physician's orders for antifungal powder according to the provider's policy.*Implemented for one of one resident (5) who had physician-ordered speech services.

Inspectors wroteBased on observation, interview, and record review, the provider failed to ensure two of two sampled residents (1 and 17) who used side rails (bars attached to the bed) had documented alternatives attempted prior to the implementation of using those side rails and the risks and benefits of using those side rails were reviewed with the resident or the resident's representative.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure two of two sampled residents (19 and 35), who received an altered texture therapeutic diet of pureed food, received the required nutritional value and the required amount of pureed food served to them.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure food safety standards were followed by three of three employees (certified nursing assistant (L), guest services aide (GSA)/cook R, and cook Q), completed proper hand hygiene during one of one meal service.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, interview, and document review, the provider failed to ensure one of one resident's (1) right to refuse a vaccination was honored. Failure to do so resulted in the resident receiving the vaccine and voicing feelings of frustration as she was not able to make her own decision. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident.

Inspectors wroteBased on record review, interview, observation, and policy review, the provider failed to ensure resident care plans were revised to reflect the current enhanced barrier precautions (EBP) need for three of eight sampled residents (11, 15, and 32) who required EBP.

Inspectors wroteBased on observation, manufacturers' instructions review, and policy review the provider failed to ensure two of two randomly observed residents' (21 and 26) insulin had been administered according to the instructions for use by one of one registered nurse (RN) F. Those observations created a medication error rate of 9.68%.

Inspectors wroteA. Based on observation, interview, and policy review, the provider failed to ensure one of one registered nurse (RN) unit manager C had performed glove changes during a dressing change for one of one sampled resident (15).

Inspectors wroteBased on record review and interview, the provider failed to ensure Minimum Data Set (MDS) assessments for 5 of 13 sampled residents (4, 5, 9, 13, and 17) were completed in a timely manner.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to ensure three of three newly admitted sampled residents (228, 229, and 230) had a baseline care plan that had been established and reviewed with the resident, their representative, or their responsible family member.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to dispose of expired medications in one of one Nexsys automated dispensing cabinet (ADC).

Inspectors wroteBased on observation, interviews, record review, and policy review, the provider failed to provide care in a considerate manner for two of thirteen (10 and 17) sampled residents.

Inspectors wroteBased on interview, medical record review, and document review, the provider failed to notify two of thirteen sampled residents (12 and 20) of a room and/or roommate change.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to support the sleep schedule for one of nine residents (5) interviewed.

Inspectors wroteBased on interview and record review, the provider failed to provide appropriate follow-up interventions for one of one sampled residents (20) who had made suicidal ideations.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure the resident's physician and the director of nursing (DON) acted upon the pharmacist's recommendations for one of five sampled residents (4).

Inspectors wroteBased on record review, interview, policy review, and Centers for Disease Control and Prevention (CDC) recommendations, the provider failed to ensure two of five randomly sampled residents (6 and 25) had documented pneumonia vaccination administration or the refusal of the vaccine in their medical records.