Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Lake Norden during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dysphagia, and an order for a pureed diet with nectar-thick liquids was given an Uncrustable sandwich, a mechanical soft food, by a CNA after consultation with an LPN. Both staff were aware of the resident’s prescribed diet, and the resident had a history of coughing or choking with meals. After taking several bites, the resident began choking, prompting the CNA to initiate back blows and the LPN to perform the Heimlich maneuver and chest thrusts until food remnants were removed from the airway and mouth. The resident was then monitored, and the incident was reported to family, the physician, hospice, and facility leadership. The facility’s pureed diet policy required smooth, lump-free, extremely thick foods and did not permit transitional foods without SLP or physician assessment, which the sandwich did not meet.
A nurse documented multiple HS and morning medications as given in the eMAR without actually administering them, and applied an incorrect Fentanyl patch dose to a resident. An internal audit found that numerous medications for several residents remained in bubble packs for the relevant HS and morning passes, even though they were signed out as administered. Affected residents, many with cognitive impairment, did not receive ordered medications such as antiseizure drugs, blood pressure medications, antidepressants, antipsychotics, thyroid replacement, GI agents, and sleep aids. The facility’s own medication administration policy, which requires accurate administration and documentation and proper handling of unadministered doses, was not followed.
A deficiency was identified in the care planning for residents in the memory care unit, where call lights were often placed out of reach, and residents were unable to use them effectively. Staff interviews revealed a lack of communication and awareness regarding call light placement, with some lights intentionally placed out of reach for safety reasons. The care plans did not accurately reflect the residents' needs or abilities, contrary to the facility's policy on individualized, resident-centered planning.
Failure to Follow Ordered Pureed Diet Leads to Choking Incident
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician-ordered pureed diet with nectar-thick liquids for a resident with dysphagia, resulting in the resident being given an inappropriate snack texture. The resident had severe cognitive impairment with a BIMS score of 0, diagnoses including Alzheimer’s disease, delusional disorder, depression, restlessness and agitation, and was dependent on staff to ensure physician orders were followed. Nutritional assessments and physician orders documented that the resident was to receive a regular pureed (Level 1) diet with nectar-thickened liquids due to dysphagia and a history of coughing or choking during meals or when swallowing medications. Despite this, staff were aware of the resident’s ordered diet texture and fluid consistency through the Kardex, meal tickets, care plans, and diet orders. On the night of the incident, the resident was awake and walking in the main lobby when he stated he was hungry. A CNA had him sit at a table by the nurse’s station and obtained an Uncrustable sandwich from the kitchen refrigerator after asking an LPN what to get for a snack. The CNA reported that the LPN suggested the Uncrustable sandwich, while the LPN stated she was aware of the resident’s pureed diet with nectar-thick liquids and that the CNA had asked if it was okay, but she did not answer. Both the CNA and LPN acknowledged that the resident had been given Uncrustable sandwiches in the past without apparent problems, and the CNA knew the resident’s ordered diet was regular puree with nectar-thickened liquids. The Uncrustable sandwich is a mechanical soft texture food, not appropriate for a pureed diet as later confirmed by the speech language pathologist. After the resident took several bites of the Uncrustable sandwich, he set it down, stood up, and became unresponsive to verbal inquiry about choking. The CNA initiated back blows and called the LPN for assistance. The LPN immediately began the Heimlich maneuver while the resident was standing, then seated, and eventually on the floor where chest thrusts were performed. Food remnants from the sandwich were visualized in the resident’s mouth and removed by the CNA via finger sweep, with additional small remnants removed by the LPN. The resident subsequently produced phlegm, made noises, and was able to take sips of thickened liquid. Vital signs were obtained and he was monitored in a recliner near the nurse’s station. The incident was reported to the family, physician, hospice, and facility leadership, and both the CNA and LPN were suspended pending investigation for not providing the correct diet texture. The facility’s pureed diet policy specified that foods must be pureed to a smooth, lump-free, extremely thick consistency and that transitional foods are not allowed unless assessed and ordered by an SLP or physician, underscoring that the Uncrustable sandwich did not meet the ordered diet requirements.
Multiple Missed and Incorrectly Documented Medication Doses, Including Wrong Fentanyl Patch Dose
Penalty
Summary
The deficiency involves a failure to ensure residents were free from significant medication errors when one LVN documented medications as administered in the electronic MAR (eMAR) without actually giving them, and applied an incorrect dose of a Fentanyl patch to a resident. On two consecutive days, multiple residents did not receive their scheduled HS and morning medications, even though the eMAR showed the medications as given. An internal audit conducted after a resident reported receiving morning medications revealed that, on the Alzheimer Care Unit, most residents’ HS medications from the prior day remained in the bubble cards, and on the main floor, some residents’ morning medications also remained in the bubble cards despite being signed out on the eMAR. The same LVN had also applied a 25 mcg Fentanyl patch instead of the ordered 12 mcg dose to one resident. The medication system in place used bubble cards with 30 individual “bubbles” per card and colored stickers indicating a.m., p.m., or HS passes, and nurses were expected to punch medications out of the bubble cards into a cup, administer them, and then immediately document administration in the eMAR. According to nursing staff, medications that were not administered would remain in the bubble pack for that date, and cards for a completed pass would be moved to the back of the row. However, review and interviews showed that for the HS pass on one date and the morning pass on the following date, medications for multiple residents remained in the bubble packs and the cards were not moved, even though the eMAR entries had been completed as if the medications were given. The DON stated she was not auditing bubble cards for medication errors at the time and had not previously encountered medications being signed out in the eMAR while remaining in the bubble cards before this incident. Record review identified specific residents affected by these errors. One resident with severely impaired cognition and an order for a 12 mcg/hr Fentanyl patch every 72 hours received a 25 mcg patch instead. Another resident with severe cognitive impairment and multiple orders for antiseizure, blood pressure, antipsychotic, and other medications did not receive those HS medications, though they were signed out as given. Additional residents with varying levels of cognitive impairment and intact cognition did not receive ordered medications including antidepressants, antianxiety agents, blood thinners, seizure medications, thyroid replacement, gastrointestinal medications, supplements, and sleep aids, even though the eMAR reflected administration. The facility’s Medication Administration Policy required medications to be administered according to prescriber orders, prohibited using one resident’s medications for another, and required that the individual who administers the medication document directly after giving the dose and document any withheld or unadministered doses per procedure, which did not occur in these events.
Deficiency in Care Plan Updates for Call Light Accessibility in Memory Care Unit
Penalty
Summary
The report identifies a deficiency in the care planning and implementation for residents in the memory care unit (MCU) of the facility. Specifically, the care plans for five residents with impaired cognition were not updated to accurately reflect their abilities to use call lights effectively. Observations revealed that call lights were often placed out of reach, and residents were either unaware of their presence or unable to use them. For instance, one resident's call light was attached to a curtain on the opposite side of the room, making it inaccessible, while another resident's call light was clipped to the wall, also out of reach. Interviews with staff, including a CNA and the Alzheimer's care director, highlighted a lack of awareness and communication regarding the placement and accessibility of call lights. The Alzheimer's care director admitted that call lights were sometimes intentionally placed out of reach for safety reasons, but this was not reflected in the care plans. The MDS coordinator, responsible for updating care plans, was unaware of these practices and had been instructed to include call light accessibility in all care plans, regardless of the residents' abilities. The facility's policy on care plans emphasizes individualized, resident-centered planning, yet the care plans did not accurately represent the residents' needs or abilities. Interviews with the administrator, director of nursing, and regional nurse consultant confirmed that the care plans should reflect the residents' individualized needs, but acknowledged that some residents might not be able to use their call lights. The deficiency lies in the failure to update care plans to reflect the actual conditions and needs of the residents, particularly regarding the accessibility and use of call lights.
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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 Lake Norden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Estelline Nursing And Care Center | 12.7 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society De Smet | 21.6 mi | ★★★★★ | 3 | 0 |
| Jenkin's Living Center | 22.3 mi | ★★★★★ | 6 | 0 |
| Avantara Watertown | 22.9 mi | ★★★★★ | 29 | 2 |
| United Living Community | 27.6 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.