Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avantara Groton during CMS and state inspections, most recent first.
Baseline care plans were not completed and implemented within the required timeframe for multiple newly admitted residents. A resident-centered plan was reviewed late or not documented as reviewed, and several care plan items were added days after admission rather than within 48 hours. The records also showed generic interventions and missing resident-specific details, including nutrition needs for a resident without teeth and delayed ADL support planning.
MDS assessments were inaccurately coded for multiple residents. One resident with serious mental illness had a Level I PASRR indicating evidence of SMI/IDD, yet the MDS coded PASRR status as No; another resident on Trulicity was incorrectly coded as receiving insulin; and a third resident was incorrectly marked as up to date on pneumococcal vaccines despite only having documentation of PCV13. Two residents were also incorrectly coded as having significant weight loss even though their weight records showed weight gain or no significant loss.
Medications were not labeled and stored per policy for four residents with orders for miconazole 2% powder. Surveyors found open bottles in a shared bathroom and a nightstand drawer, including one bottle with only a handwritten resident name and no pharmacy label. Staff stated that CNAs sometimes applied creams and powders and then told the nurse, and the regional nurse consultant agreed that the person applying the powder should be the one documenting it in the MAR.
A CNA did not perform hand hygiene while assisting residents during dining, another CNA did not perform hand hygiene before donning gloves or after glove removal, and a CNA failed to wear gown and gloves while caring for a resident on contact precautions. Shower room cleaning was also inconsistent: staff used a household cleaner in the tub rooms, did not consistently use the hospital-grade disinfectant as directed, and did not fully clean/disinfect the shower area or resident care items before returning them to storage.
Code Status Not Accurately Documented in EMR: The facility failed to ensure that residents' code status was current and accurately reflected in the EMR for three residents. One resident stated he wanted DNR status, but his banner, physician orders, admission note, and EMR did not consistently document it. Another resident had conflicting full code and DNR documentation with a delay between the representative's DNR form and the physician's signature. A third resident's EMR banner showed DNR despite hospital paperwork showing full resuscitation, and no signed document confirming the code status was found.
The facility failed to follow its medication documentation policy for multiple residents with orders for miconazole powder. CNAs and nurses described a practice where CNAs applied creams and powders, but the applications were not documented in the MAR, and open bottles were found in resident areas without proper labeling, including in a shared bathroom. The facility also did not carry out a physician-ordered speech therapy service for a resident with severe cognitive impairment, Alzheimer’s disease, dysphagia, malnutrition, and a recent hospitalization for aspiration pneumonia.
Two residents had quarter-length side rails in the up position for repositioning and transfers, but the EMR did not show that alternatives were attempted before the side rails were installed. Although both residents had intact cognition and consent was obtained, there was no documentation that the risks and benefits of the side rails were reviewed with the resident or representative before consent. An LPN and regional nurse consultant confirmed the missing documentation and stated alternatives were not always attempted before side rail use.
Two residents on puree diets did not receive pureed foods prepared and served as required. A cook used water to puree vegetables, which was acknowledged to reduce nutritional value, and another cook poured pureed food from a pan without using the required scoop to measure portions. The CDM and regional nurse consultant confirmed the facility’s puree food preparation and menu portion serving policies were not followed.
Improper hand hygiene and glove use during meal service. A CNA touched two residents’ wheelchairs and fed two residents without cleaning her hands between contacts. A GSA/cook used the same gloves to handle utensils, tinfoil, a pan lid, and a cheeseburger bun, and another cook opened a bun bag and handled a bun with a potentially contaminated gloved hand. Facility policy required hand hygiene after resident contact and gloves for one task only.
A resident's right to refuse a COVID-19 vaccination was not honored when an LPN misread a declination form and administered the vaccine despite the resident's verbal refusal. The resident expressed frustration over the lack of autonomy in decision-making. The incident was reported, and the resident's power of attorney was informed and accepted the situation. No further concerns were identified among other residents and staff.
The facility failed to update care plans for three residents requiring Enhanced Barrier Precautions (EBP). A resident with a pressure ulcer and two others with EBP signs on their doors did not have their care plans revised to reflect this need. The DON and RN unit manager confirmed the oversight.
A medication error rate of 9.68% was observed when an RN failed to prime insulin pen needles before administering Aspart, Degludec, and Lispro insulin to two residents. The manufacturer's instructions require priming to ensure accurate dosing, but the facility's policy lacked specific guidance for insulin pen use.
The facility failed to ensure proper infection control practices during resident care. An RN did not change gloves or perform hand hygiene appropriately during a dressing change, and a resident with a wound vacuum was not placed on enhanced barrier precautions. Additionally, a CNA did not follow proper hand hygiene and glove use during foley catheter care, using improper technique that could introduce bacteria.
Baseline Care Plans Not Completed or Individualized Within Required Timeframe
Penalty
Summary
The provider failed to develop and implement a resident-centered baseline care plan within 48 hours of admission for four of five sampled residents who were recently admitted. The report identified that baseline care plans were reviewed or initiated several days after admission for residents 1, 3, and 37, and that resident 20 did not have a documented intervention on the care plan until 11/14/25. Staff interviews confirmed that the baseline care plan was expected to be completed within 48 hours, reviewed with the resident or resident representative within 48 to 72 hours, and documented as reviewed, but this did not occur as expected for the sampled residents. For resident 3, the baseline care plan was reviewed three days after admission, and several care plan focus areas and interventions were not initiated until days later, including enhanced barrier precautions, assistance with ADLs, and detailed ADL self-care performance interventions. For resident 37, the EMR did not contain a progress note showing the baseline care plan had been reviewed with the resident or representative, and the care plan focus areas and interventions were initiated after admission rather than within the required timeframe. The resident also had intact cognition based on a BIMS score of 14, but there was no documented review of the plan with him. For resident 1, the baseline care plan was reviewed three days after admission. The admission summary noted that he had no teeth or dentures and that a mechanical soft diet had been requested, but the alteration in nutritional status interventions did not identify that he had no teeth or that an altered diet order had been requested. His ADL self-care performance deficit and impaired mobility interventions were not initiated until 13 days after admission. For resident 20, the record showed no documented intervention on the care plan until 11/14/25, and the care plan interventions listed were generic ADL items such as assistance with appliances, encouragement of participation, DME, and transfer assistance.
MDS Assessments Were Inaccurately Coded for PASRR, Insulin, Pneumococcal Status, and Weight Loss
Penalty
Summary
The facility failed to ensure MDS assessments were accurately coded for five sampled residents in the areas of PASRR status, insulin administration, pneumococcal vaccination status, and weight loss. Resident 8 had diagnoses including delusional disorder, anxiety disorder, PTSD, and bipolar disorder, and the EMR showed a Level I PASRR indicating evidence of serious mental illness or IDD with no Level II PASRR in the record; however, the 9/19/25 comprehensive MDS coded A1500 as No. The MDS coordinator later verified that resident 8 had a Level II PASRR and that the MDS was coded inaccurately. Resident 4 had diabetes and an order for Trulicity, a GLP-1 agonist, yet the 9/9/25 quarterly MDS coded N0350A as if insulin had been administered one time during the look-back period, and the MDS coordinator verified he was not on insulin. Resident 37 had documentation of a PCV13 vaccine on 10/6/2020, with no record of additional pneumococcal vaccines and no documentation that the next dose had been offered or refused, yet the 12/2/25 comprehensive MDS coded him as up to date on pneumococcal vaccinations. The MDS coordinator stated she manually entered that response and later verified the assessment was coded inaccurately. The regional nurse consultant also verified that resident 8’s PASRR coding, resident 4’s insulin coding, and resident 37’s pneumococcal vaccination coding were incorrect. Resident 19’s 11/17/25 MDS coded a significant weight loss of 5% in 30 days or 10% in 180 days, but the weight record showed 93.2 lbs on 11/17/25 compared with 90.2 lbs on 10/17/25, 90.8 lbs on 8/15/25, and 95.6 lbs on 5/12/25, reflecting weight gain or no significant loss rather than the coded loss. Resident 7’s 9/12/25 MDS also coded significant weight loss, but the weight record showed 102.4 lbs on 9/9/25 compared with 97.0 lbs on 8/11/25 and 98 lbs on 6/6/25, again reflecting weight gain rather than significant loss. The dietary manager confirmed she completed section K, had limited MDS training, was not aware of the section K instructions in the RAI manual, and acknowledged that both residents were miscoded.
Improper Labeling and Storage of Resident Miconazole Powder
Penalty
Summary
Medications and biologicals were not labeled and stored in accordance with the facility policy for four sampled residents with physician orders for miconazole 2% powder. In resident 23's shared bathroom, surveyors observed an open bottle of miconazole 2% powder on the shelf with the resident's first name and last initial handwritten on it, but no pharmacy label. In resident 18's room, surveyors observed an open bottle of miconazole powder in the nightstand drawer with no handwritten resident name and no pharmacy label. The physician orders for residents 18, 20, 23, and 34 directed application of miconazole 2% powder to intertriginous areas twice daily, and none of these residents had orders to self-administer the powder.
Infection Control Lapses During Resident Care and Shower Room Cleaning
Penalty
Summary
Standard infection control practices were not followed during resident care and environmental cleaning. During dining room observation, a CNA touched the handrails of one resident’s wheelchair, then another resident’s wheelchair, and later fed one resident and then another resident with the same hand without performing hand hygiene between residents. The provider’s hand hygiene policy required hand hygiene before and after direct resident contact, after contact with objects in the resident’s immediate vicinity, and before and after handling food. In the 100-hall tub room, a spray bottle of Fabuloso 2X lavender cleaner and a bottle of Medline Micro-Kill Q3 were present. The laundry basket inside the room had visible brown residue, the shower chair seat was wet, and a purple liquid was in the bucket under the shower chair. A CNA stated Fabuloso was used by night staff to clean the tub room floor and Micro-Kill was used after showering a resident, but the disinfectant was allowed to sit only until just before the next resident shower and then surfaces were rinsed. In the 300-hall shower room, Fabuloso was also present, and there was no Micro-Kill bottle in the room. A resident on contact precautions was transported from the tub room to his room without a gown or gloves, and the CNA then put on PPE only after entering the room. Another CNA entered the tub room to shower the same resident without a gown or gloves, applied gloves without hand hygiene, cleaned only the shower chair and bucket, did not spray the surrounding walls or floor, removed gloves without hand hygiene, and placed the resident’s shampoo and body wash bottles back into a cabinet without cleaning their exteriors. The nurse consultant stated the resident’s shampoo and stock body wash should have been cleaned before being returned to the cabinet because they could have been contaminated by touch or splash during the shower.
Code Status Not Accurately Documented in EMR
Penalty
Summary
The facility failed to ensure that the code status for three sampled residents was currently and accurately documented in the electronic medical record. Resident 37, who had a BIMS score of 14 indicating intact cognition, told staff during interview that he wanted DNR status if his heart or breathing stopped. However, his EMR banner was blank in the advanced directives area, his physician orders did not include his wishes, his admission progress note did not state his resuscitation preference, and his EMR did not otherwise document his DNR wishes. His chart also contained a signed advanced directive from a previous admission that indicated CPR should be initiated. Resident 1's record showed conflicting code status information. His admission progress note stated he was full code per his wife, but later his representative signed a form indicating DNR status, which was then signed by the physician on a later date. A DNR physician order was present, but the regional nurse consultant acknowledged the time lapse between the representative's designation of DNR and the physician's signature created a period when the resident's advanced directive wishes may not have been followed. Resident 23 was admitted from the hospital with discharge paperwork listing full resuscitation, yet her EMR banner stated DNR. There was no signed document in her EMR confirming her code status wishes, although the social services director/interim administrator documented that DNR status remained and that the resident confirmed DNR wishes. Staff interviews showed the facility expected code status to be entered on admission into the EMR banner and physician orders, and the facility policy stated each resident was to choose advance directives on admission and that the choice would be documented in the medical record and care planned during the admission process.
Failure to Document Topical Medication Administration and Follow Ordered Speech Therapy
Penalty
Summary
The nursing facility failed to follow its medication administration documentation policy for four sampled residents with physician orders for miconazole 2% powder. Observation showed an open bottle of miconazole powder with resident 23’s first name and last initial handwritten on it in a shared bathroom used by four residents, with no pharmacy label on the bottle. Another resident had an open bottle of miconazole powder in the drawer of a nightstand, also without a resident name or pharmacy label, and stated that CNAs would apply the powder when she used the bathroom. A CNA stated that nurses got creams and powders from the medication room, that CNAs were told in daily huddles to apply creams, that she applied creams and powders to prevent moisture in residents’ skin folds, and that she did not document those applications in the MAR. The regional nurse consultant agreed that the person who applied the medicated powder should be the person to document it in the MAR and that multiple bottles in a shared bathroom created the potential for using the wrong resident’s product. The facility also failed to implement a physician-ordered speech therapy service for a resident with severe cognitive impairment, Alzheimer’s disease, dysphagia, protein-calorie malnutrition, and a need for assistance with personal cares. The resident had been hospitalized for aspiration pneumonia and had a physician order for speech therapy services, but review of the EMR found no documented speech therapy evaluations or treatments. The regional nurse consultant confirmed that the resident had not received speech therapy services and acknowledged that the provider did not follow its policy requiring all physician orders to be followed as written and the physician to be notified when an order is not followed for any reason.
Failure to Document Alternatives and Risk-Benefit Review Before Side Rail Use
Penalty
Summary
The facility failed to ensure that two residents who used side rails had documented alternatives attempted before the side rails were implemented and that the risks and benefits of the side rails were reviewed with the resident or representative before consent was obtained. One resident, who had a BIMS score of 15 indicating intact cognition, had quarter-length side rails in the up position at the head of the bed and used them to reposition and transfer in and out of bed. Her EMR showed a physician order for enabler bars on both sides of the bed and a Side rail/Other Device Evaluation that documented she requested the side rails, but the assessment did not show that any alternatives were attempted before installation, and there was no documentation of the risks and benefits being reviewed before she consented. A second resident, who had a BIMS score of 13 indicating intact cognition, also had quarter-length side rails in the up position at the head of the bed and used them for repositioning in bed. His EMR included a physician order for bilateral enabler bars and a Side rail/Other Device Evaluation that documented he requested the side rails, but the assessment did not include whether any alternatives were attempted before implementation. His representative gave consent for the side rails, but there was no documentation of the risks and benefits of the side rails or that those risks and benefits were reviewed with the resident or representative before consent. Staff interviews confirmed that not all residents who requested or were suggested to use side rails had alternatives attempted prior to installation, and that the risks and benefits were not included in the assessment.
Pureed Diets Prepared With Water and Served Without Measured Portions
Penalty
Summary
The provider failed to ensure that two sampled residents, both ordered a puree texture diet, received pureed foods prepared and served with the required nutritional value and measured portions. During observation, cook Q stated that pureed broccoli was prepared with water and that water was often used to puree vegetables, while broth was used for other foods; she agreed that using water reduced the nutritional value of the vegetables. The certified dietary manager later confirmed that pureed foods were to be served using the correct-sized scoop listed on the menu spreadsheet and that foods were not to be poured from a pan without measuring. During another observation, cook R was seen dishing pureed food items by pouring them from a pan without using a scoop to measure the amounts. Review of the residents’ EMRs showed physician-ordered puree diets for both residents. Policy review showed that pureed foods were to be prepared using standardized recipes to preserve maximum nutritive value, that water was not to be used to thin pureed foods, and that the proper scoop number or equal division was required to provide equal portions. The regional nurse consultant confirmed that the cooks did not follow the facility’s pureed food preparation and menu portion serving policies.
Improper Hand Hygiene and Glove Use During Meal Service
Penalty
Summary
Food safety standards were not followed during one meal service when three employees failed to use proper hand hygiene and glove practices. During observation in the dining room, a CNA sat between two residents, pulled both residents’ wheelchairs closer to the table without performing hand hygiene between contact with the wheelchairs, and later fed one resident a bite of food and then fed another resident with the same hand without cleaning her hands in between. The facility’s hand hygiene policy required hand hygiene before and after direct resident contact and after contact with objects in the resident’s immediate vicinity. During the same meal service, a GSA/cook served food while wearing one-use gloves and used the same gloves to handle multiple items, including utensils, tinfoil, a pan lid, and a cheeseburger bun. She removed a cheeseburger from a pan, unwrapped it, and handled the bun with the same gloves after touching other items. Another cook wore one glove on one hand, opened a bag of hot dog buns with both hands, reached into the bag, and removed a bun with the gloved hand. The facility’s glove-use policy stated gloves are for one task only, and the CDM and RNC confirmed that ready-to-eat food should not be touched with potentially contaminated gloves or ungloved hands.
Resident's Right to Refuse Vaccination Not Honored
Penalty
Summary
The provider failed to honor a resident's right to refuse a COVID-19 vaccination, resulting in the resident receiving the vaccine against her wishes. During a vaccination clinic, an LPN misread the resident's vaccine declination form, mistakenly believing that the resident's power of attorney had consented to the vaccination. Despite the resident's verbal refusal and expression of frustration, the LPN insisted that the resident's family wanted her to receive the vaccine, leading to the administration of the vaccine. The resident expressed feelings of frustration and a lack of autonomy in decision-making following the incident. The LPN acknowledged the error, confirming that the resident had clearly stated her refusal. The incident was reported to the social services designee, who informed the director of nursing. The resident's power of attorney was contacted and informed about the situation, and they accepted that the resident had received the vaccine. Interviews with other residents and staff revealed no additional concerns regarding resident rights or similar errors.
Failure to Update Care Plans for Enhanced Barrier Precautions
Penalty
Summary
The provider failed to ensure that the care plans for three residents were updated to reflect the need for Enhanced Barrier Precautions (EBP). Resident 11, who had a pressure ulcer on her left calf, was readmitted with a wound vacuum, yet her care plan was not revised to include EBP. The Director of Nursing (DON) acknowledged that the care plan should have been updated during care conferences or when changes occurred, but it was not. Similarly, residents 15 and 32 had EBP signs on their doors and personal protective equipment available, indicating the need for EBP. However, their care plans did not reflect this requirement. Resident 32 had an indwelling Foley catheter, and resident 15 had an open wound on his coccyx region. Both the RN unit manager and the DON confirmed that the care plans for these residents should have included EBP but were not updated accordingly.
Medication Error Due to Improper Insulin Administration
Penalty
Summary
The provider failed to ensure proper administration of insulin for two residents, resulting in a medication error rate of 9.68%. During observations, a registered nurse (RN) did not prime the insulin pen needles before administering Aspart and Degludec insulin to one resident and Lispro insulin to another. The manufacturer's instructions for the Lispro Injection KwikPen clearly state that priming is necessary before each injection to ensure the correct dose is delivered. The facility's medication administration policy did not include specific instructions for the use of insulin pen devices, contributing to the oversight in proper insulin administration.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The provider failed to ensure proper infection prevention and control practices during a dressing change performed by an RN unit manager for a resident. The RN did not change gloves or perform hand hygiene at appropriate times, such as after handling soiled items and before touching clean supplies. The RN also used a marker from her pocket, which was not a clean area, and did not sanitize the resident's dressing container before returning it to the medication cart. These actions were contrary to the facility's hand hygiene policy. Another deficiency was observed with a resident who had returned from the hospital with a wound vacuum device. The resident was not placed on enhanced barrier precautions (EBP) as required by the facility's policy for residents with wounds or indwelling devices. Staff did not wear gowns or gloves when providing care, and there was no signage indicating EBP until later. The director of rehabilitation confirmed that EBP measures were not in place during her care of the resident. Additionally, a CNA failed to perform appropriate hand hygiene and glove changes during foley catheter care for a resident on EBP. The CNA did not wash her hands before donning PPE or after performing tasks that required it, such as emptying the catheter. She also used improper technique by cleaning the groin area first and using the same towel for multiple areas, which could introduce bacteria. These actions were inconsistent with the facility's hand hygiene policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Groton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethesda Home Of Aberdeen | 17.7 mi | ★★★★★ | 7 | 0 |
| Sun Dial Manor | 18.6 mi | ★★★★★ | 1 | 0 |
| Avera Mother Joseph Manor Retirement Community | 18.7 mi | ★★★★★ | 9 | 0 |
| Prairie Heights Healthcare | 19.1 mi | ★★★★★ | 0 | 0 |
| Aberdeen Health And Rehab | 20 mi | ★★★★★ | 13 | 1 |
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