Avantara Watertown

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, observation, record review, and policy review, the provider failed to ensure residents received care in accordance with their plan of care by two of two certified nursing assistants (CNAs) (N and Q) who did not change six of eight sampled residents' (1, 2, 3, 4, 5, and 6) incontinence (involuntary urine or bowel leakage) products during the night shift and did not reposition one of one sampled resident (4) who was found sideways in bed with urine-stained bedsheets, and by one of one contracted travel CNA (Z) who left one of one sampled resident (5) alone in the dining room for over three hours.

Inspectors wroteA. Based on observation, interview, record review, and policy review, the provider failed to ensure resident safety regarding the side rails/grab bars and mattresses on the resident's beds were assessed for entrapment (trapped between the rail, mattress, or bedframe spaces) risk for three of three sampled residents (23, 35, and 48) who had loose side rails/grab bars on their beds and three of three sampled residents (23, 32, and 35) who had an unsecured mattress on their bed. Those failures put the identified residents at risk for entrapment injury or harm.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to protect the resident's right to be free from sexual abuse for one of one sampled resident (21) who reported he was touched in a private area without his consent by one of one contracted travel certified nursing assistant (CNA) (E). Immediate Jeopardy (IJ) at F600, with a scope and severity of J, began on 4/21/26 at 9:17 a.m. upon observation of resident 21 in the hallway when he reported to registered nurse (RN) D that he had a concern of being touched by a staff member on 4/21/26. Resident 21 reported that contracted travel CNA E had touched him in a private area without his consent, which upset the resident. [...]

Inspectors wroteBased on observation, interview, record review, policy review, and manufacturer's instructions review, the provider failed to ensure residents were free from significant medication errors for one of one sampled resident (7) who was not administered his physician-ordered carbidopa/levodopa (a medication to treat Parkinsons disease; [...]

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure all residents' right to privacy and confidentiality of protected health information (an individual's health, treatment, and payment information, also known as PHI) were protected related to a facility census document that was stored in an area accessible to anyone who passed by.

Inspectors wroteBased on observation, interview, record review, policy review, and job description review, the provider failed to ensure the facility was operated and administered by administrator A and director of nursing (DON) B in a manner that ensured quality of life and overall well-being for all 45 residents in the facility.

Inspectors wroteBased on observations, interviews, record reviews, and policy reviews, the governing body failed to ensure the facility was operated in a manner that ensured the safe management and overall well-being of 45 residents in the facility.

Inspectors wroteBased on interview and quality assurance and performance improvement (QAPI) plan policy review, the provider failed to ensure they had identified and corrected quality deficiencies when they occurred throughout the facility and that performance improvement projects (PIP) were thoroughly identified, implemented, or monitored related to quality of care, quality of life, and safety concerns for areas affecting residents such as siderails on residents' beds, incident reporting, medication administration and storage, and baseline care plans.1. Interview on 4/29/26 at 9:30 a.m. with administrator A regarding the QAPI program and committee revealed that she was the QAPI coordinator for the provider and that each department manager conducted their own audits. She reviewed and consolidated the reports to be discussed at the QAPI meeting. [...]

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, interview, record review, and policy review, the provider failed to ensure that staff protected three of four sampled resident's (3, 22, 37) right to a sense of dignity, respect, and self-determination regarding bathing preferences.

Inspectors wroteBased on interview, record review, resident council meeting interview, and policy review, the provider failed to:*Ensure prompt response to call light times, and that the necessary cares and services were provided within a timely manner for four of four residents (2,16, 24, and 61) to maintain their physical, mental, and emotional well-being. *Implement an effective grievance process to ensure residents' have the knowledge on how to file a grievance, where the grievance forms are located at and a process in place on how to file grievances anonymously. Findings Include:1. Interview on 4/21/26 at 9:38 a.m. with resident 16 revealed the problems with living in this facility is that she is not getting help when she needs it. She revealed that sometimes she had to wait an hour to have staff come to help her in her room. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to implement procedures to ensure allegations of abuse were reported to the required entities for two separate allegations of abuse:*A sexual abuse allegation made by one of one sampled resident (21) to registered nurse (RN) F and RN D involving certified nursing assistant (CNA) E and an unidentified staff member.*A possible financial abuse allegation made by one of one sampled resident's (40) family member to social services designee (SSD) J.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to ensure the resident's baseline care plan (personalized plan that addresses a resident's care needs, goals, and interventions) included the minimum healthcare information necessary to properly care for the resident, and that the care plan was completed within 48 hours of the resident's admission to the facility for six of 19 sampled residents (2, 4, 7, 33, 40, and 59), and was reviewed with, and a copy was offered to the resident or the resident's representative within 48 hours of the resident's admission to the facility for six of seven newly admitted sampled residents (2, 4, 7, 33, 40, and 59).

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure the care plan (personalized plan that addresses a resident's care needs, goals, and interventions) was reviewed and revised to reflect the current care needs for four of nineteen sampled residents (13, 33, 38, and 40).

Inspectors wroteBased on observation, record review, interview and policy review the provider failed to ensure infection control practices were followed regarding the residents' nasal cannulas (flexible tubing with prongs that delivers oxygen through the nose) being stored properly when they were not in use for one of three sampled residents (1) who required the use of oxygen, and two of three sampled resident (2, and 48) who used a nebulizer (a device that converts liquid medication into an inhalable mist) machine that was not cleaned after each use by the nursing staff and per their policy.

Inspectors wroteBased on record review, observation, interview, and policy review, the provider failed to ensure informed consents for side rails were obtained before the side rails were installed for seven of 25 sampled resident (4, 15, 16, 23, 25, 32, and 36), physician's orders, in accordance with the provider's policy, were obtained before side rails were installed for 12 of 25 sampled residents (2, 3, 4, 8, 15, 16, 17, 19, 29, 32, 36, and 45), alternatives to the side rails were attempted before the side rails were installed for 21 of 25 sampled residents (3, 4, 8, 15, 16, 17, 19, 22, 23, 24, 25, 27, 29, 31, 33, 35, 36, 37, 45, 47, and 48), and entrapment zone assessments were completed on 23 of 25 sampled resident (2, 3, 4, 8, 12, 14, 15, 16, 17, 19, 22, 23, 24, 27, 31, 32, 33, 35, 36, 37, 45, 47, and 48) who had side rails on their bed.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure the staff educated the resident or resident's representative of the risk versus benefits of medications or of alternative treatments to make an informed decision and consent for the use of psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) before they were given for two of two sampled residents (3 and 33).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure four of four sampled residents (2, 17, 28, and 48) had been assessed to determine their ability to safely self-administer medications, and a physician's order had been obtained to self-administer those medications.

Inspectors wroteBased on interview, record review, and policy review, the provider failed to ensure there was documented need, treatment alternatives, non-pharmacological interventions, and a specific condition identified for one of one sampled resident (33) who was started on an antipsychotic (a drug that alters neurotransmitter activity in the brain to reduce symptoms of mental health conditions) medication.

Inspectors wroteBased on record review, interview, and policy review the provider failed to ensure the Office of State Long-Term Ombudsman (an advocate of residents' overall quality of care and rights) was notified when a resident discharged from the facility, for one of three sampled residents (54).

Inspectors wroteBased on record review, interview, policy review, and the 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 two of two sampled residents' (2 and 40) Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop and individualized care plan to manage the resident's care needs) assessments were accurately coded for the areas required for the Pre-admission Screening and Resident Review (PASRR) (a mandatory federal process that ensures people with mental illness or intellectual disabilities are not inappropriately placed in nursing homes). Findings Include: 1. Review of resident 2's EMR revealed she was admitted to the facility on [DATE] from another long-term care facility. [...]

Inspectors wroteBased on record review, interview, and policy review, the provider failed to complete a Level II (2) Preadmission Screening and Resident Review (PASRR) (a mandatory federal process that ensures people with mental illness or intellectual disabilities are not inappropriately placed in nursing homes) for one of one sampled resident (40) with a qualifying mental health diagnosis and resubmit a Level I screening PASRR for one of one sampled resident (33) who was newly prescribed an antipsychotic (a drug that alters neurotransmitter activity in the brain to reduce symptoms of mental health conditions) medication.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure the staff followed nursing professional standards of practice for notifying the physician of elevated blood glucose (the amount of glucose-a type of simple sugar-present in your blood at any given time) for one of one sampled resident (40).

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to ensure accurate and complete documentation for the destruction of fentanyl patches (potent long-acting pain patch applied on the skin) for one of one sampled resident (9).

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure a medication error rate of less than 5 percent related to a lidocaine patch (a topical pain-relieving patch) was removed as prescribed for one of one observed resident (30) by licensed practical nurse (LPN) SS and sucralfate (a medication used to treat and prevent ulcers) was administered before the noon meal as prescribed for one of one observed resident (19) by LPN KK. Those observed errors resulted in a medication error rate of 7.41%.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure the temperature was monitored in one of two sampled refrigerators in one of one medication room that had influenza vaccines stored in it and two of two observed glucometer test strip containers with a shortened expiration date (supplies that, after opening, expire before the manufacturer's expiration date) were dated when they were opened.

Inspectors wroteBased on observation, interview, and record review, the provider failed to ensure that staff honored one of one sampled resident's (22) meal choice preferences for one of four observed meals.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint report review, record review, and interview, the provider failed to ensure one of one resident (1) had been free from a significant medication error and who suffered an acute kidney injury after she was administered the incorrect dose of medication for five consecutive days. Failure to administer that medication as ordered may have contributed to resident 1's health condition and acute kidney injury. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident.

Inspectors wroteBased on observation and interview, the provider failed to preserve the dignity of three of three sampled residents (13), (145), and (146) by not ensuring urinary catheter bags (collects drained urine) were covered while residents were in the common areas.

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI), interview, record review, and policy review, the provider failed to ensure teh accountability of fentanyl patches (a controlled topical pain medication) by not monitoring and documenting the placement of the patches for three of five sampled residents (8, 30, and 144) who were administered fentanyl patches.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure expired medications were removed from one of one medication storage room.

Inspectors wroteBased on observation, interview, and record review the provider failed to ensure oral care was consistently performed and accurately documented for three of four sampled residents (2, 3, and 4).

Inspectors wroteBased on observation, interview, and record review the provider failed to ensure their pharmacy services were consistent in labeling identification information and appropriate handling information for cytotoxic agents (a toxic agent that has the ability to kill dividing cells such as cancer treatment or substance in some types of venom) for five of five sampled residents (11, 12, 13, 15, and 36) receiving such agents.