Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Watertown during CMS and state inspections, most recent first.
The facility failed to maintain safe bed systems and prevent accidents, resulting in loose side rails, unsecured or poorly fitted mattresses, and unassessed entrapment zones for multiple residents, including one who was legally blind and had a prior brain bleed after falling from bed. Maintenance logs showed incomplete or inaccurate entrapment audits, with several entrapment zones marked not applicable and some residents with rails omitted from audits, while the DON acknowledged missing side rail assessments, consents, and orders. Additional incidents included a resident with post‑stroke weakness who fell from a bed left at waist height, a resident care planned for two‑person mechanical lift transfers who was transferred by a single CNA using an incorrect sling setup, a cognitively impaired resident at risk for elopement who exited through a door with its alarm deactivated and remained outside briefly in cold weather, and a resident on anticoagulants who fell and hit her head after 11 falls in 30 days without effective revision of fall‑prevention interventions.
A resident reported that a contracted travel CNA put hands inside his pants without consent while checking whether he was wet. Staff did not promptly escalate the allegation to the DON, and the administrator did not contact law enforcement because she believed reporting would wait until the facility determined whether abuse occurred. The resident had dementia, psychosis, insomnia, and anxiety, but his BIMS score indicated intact cognition and his care plan showed he was generally independent with toileting.
A resident with Parkinson’s disease had repeated late and one missed administration of scheduled carbidopa/levodopa and clonazepam, and he reported worse tremors, jerking, sweating, and difficulty using his urinal when meds were late. Another resident with diabetes was given 7 units of Humalog after an LPN entered the roommate’s blood sugar into the EMR and used that incorrect value, even though the resident’s actual blood sugar did not require insulin.
Administrator A and the DON did not ensure effective management and oversight of resident care and services, resulting in widespread system failures affecting all 45 residents. Surveyors found deficiencies in resident dignity, informed consent for psychotropic medications, self-administration of meds, honoring meal preferences, responses to resident council concerns, protection of health information, grievance procedures, and handling of abuse allegations. Additional problems included missing or inaccurate MDS and PASSR assessments, lack of timely PASSR refiling for new diagnoses, incomplete or delayed baseline and updated care plans, failure to notify physicians of elevated blood sugars, and unaddressed accident hazards related to bed siderails. The facility also had issues with nebulizer and nasal cannula cleaning and storage, siderail assessments and consents, call light response times, controlled substance accountability, medication errors, and improper storage of drugs and biologicals, despite job descriptions assigning the administrator and DON responsibility for regulatory compliance and quality care.
Confidential Resident Census Information Left in Public View: A facility census report containing resident names, admission dates, and payer sources was left in a hanging file organizer near the nurse's desk where it could be accessed by anyone passing by. The admin acknowledged the document was confidential and in a public area, and facility policy stated PHI should not be visible to the public.
Failure of Governing Body to Ensure Safe Facility Operations: The governing body did not ensure the facility was managed in a manner that protected the safety, dignity, and overall well-being of 45 residents. Survey findings identified widespread breakdowns involving psychotropic meds, resident rights and grievances, abuse allegations, MDS/PASSR accuracy, care planning, physician notification, bed rail safety, medication management, and storage of drugs and biologicals. Administrator A stated she was told there were serious issues to address and that multiple corporate consultants were being used for support, while the Administrator and DON job descriptions assigned them responsibility for overall compliance and nursing operations.
QAPI oversight was deficient because the facility did not identify or monitor several cited quality issues, including siderails on beds, incident reporting, med administration and storage, and baseline care plans. The administrator said department managers completed audits and reports were reviewed at QAPI meetings, but confirmed these concerns were not currently on the committee's review list. The facility also relied on maintenance for siderail checks using an FDA grid system that did not identify 4.75 inches as a maximum opening height.
Staff failed to honor several residents’ stated preferences regarding where they undressed for bathing, affecting their dignity and privacy. One resident reported that a CNA repeatedly undressed him in his room, covered him with a blanket, and transported him through the hallway to the shower room, despite his expressed wish to undress in the shower room. Other residents described similar experiences, stating that the CNA did not ask their preferences and routinely undressed them in their rooms before covering them with a sheet or blanket and taking them to the tub or shower room. Staff interviews confirmed that residents, particularly those requiring a mechanical lift, were typically undressed in their rooms and then transported covered, and the DON stated that facility protocol was to follow resident preference, consistent with the written dignity and privacy policy.
A resident reported that a contracted travel CNA placed hands down his pants while he was in bed, which he described as groping and not part of his usual care routine. Two RNs received this allegation; one counseled the CNA but did not notify leadership and did not know the required reporting time frame, while the other, who knew the 2‑hour reporting requirement, also failed to promptly inform the DON or administrator, delaying notification to state authorities and omitting contact with law enforcement and the ombudsman. In a separate incident, a resident’s family member reported suspected financial abuse to the social services designee, who informed the administrator, but the concern was not reported to the state agency or investigated as an abuse allegation; instead, the family was only given contact information for outside agencies. These actions did not follow the facility’s abuse policy requiring immediate internal reporting, prompt investigation, and timely reporting of all abuse and misappropriation allegations to the state agency.
The facility failed to complete and individualize baseline care plans within 48 hours of admission for several newly admitted residents. Some residents had no baseline care plan in the EMR, while others had plans that were signed but undated or missing key information such as required assistance levels for ADLs, transfer methods, diet orders, use of assistive devices, and ordered rehab therapies. An LPN reported that nurses initiate baseline care plans at admission, and the MDS/RN acknowledged that staff may not know how to provide care if plans are not resident-specific. The regional nurse consultant confirmed that some residents lacked individualized baseline care plans and that the facility likely did not have signed baseline care plans or documentation that copies were provided, despite a policy requiring completion of a comprehensive baseline care plan within 48 hours including physician, dietary, therapy, and social service information.
The facility failed to keep several residents’ care plans accurate and resident‑specific. One resident with multiple chronic conditions had a care plan that omitted how transfers should be performed, her diet, and ordered rehab therapies. Another resident on sertraline and an antipsychotic for depression, behaviors, and poor mood had repeated episodes of agitation, combativeness, yelling, and aggression documented in progress notes, but her care plan did not identify antipsychotic use, target behaviors, or non‑pharmacological interventions. Two additional residents had care plan focus areas indicating risk of bruising and hemorrhage due to anticoagulant use even though they were not on anticoagulants, only on antiplatelet or aspirin therapy. CNAs reported relying on pocket care plans that were sometimes outdated, and clinical staff acknowledged that these care plans did not reflect current needs, contrary to facility policies on psychotropic medications and individualized care planning.
Delayed call light response and ineffective grievance process. Residents reported waiting 25 minutes to an hour for help with toileting, repositioning, and incontinent care, while a resident council meeting documented 30- to 45-minute response times. Staff said call lights should be answered within 5 to 10 minutes, but audits and interviews showed repeated delays, missing audit documentation, and a trend of grievances about long wait times. Residents also did not know how to file grievances or where forms were located, the forms were not accessible to wheelchair users, there was no anonymous drop box, and multiple grievance records lacked required documentation.
Improper storage and cleaning of oxygen and nebulizer equipment were observed for two residents with COPD and one resident who used oxygen at night. Nasal cannulas were found draped over concentrators with the prongs near or touching the floor and no storage bag attached, while nebulizer masks and chambers were left assembled with visible residue or film. Staff interviews and policy review confirmed that nasal cannulas should be stored in a bag when not in use and nebulizer equipment should be disconnected, rinsed, disinfected, air dried, and stored properly after treatment.
A review of side rail use found missing or late informed consent, physician orders, and side rail evaluations for multiple residents, along with incomplete documentation of alternatives tried before rail placement. Maintenance audits also showed inconsistent entrapment zone reviews, with some zones marked not applicable or not assessed, and observations identified loose rails and mattress gaps on several beds. The DON and maintenance leadership acknowledged missing documentation and inconsistent audit practices.
A hospice resident with liver disease and frequent scratching received escalating doses of fentanyl transdermal patches, some of which were later found to be missing and could not be located. Facility records showed multiple inconsistencies and omissions on the Transdermal Patch Controlled Drug Record, including patches removed without documented destruction times, patches applied without subsequent destruction entries, and patches documented as destroyed at the same time or shortly after being signed out for administration. Staff interviews revealed confusion about the tracking form and described storing used patches in a locked drawer when a second nurse was unavailable, while the DON acknowledged missing dates and times and that documentation did not consistently align with policy requirements for controlled substances and transdermal patch monitoring.
Incomplete informed consent for psychotropic medications was found for two residents. One resident with intact cognition had antipsychotic orders for quetiapine and later olanzapine, but the consent forms left blank the medication purpose, alternatives, and black box warning acknowledgment, and the orders did not identify a supporting dx. Another resident with intact cognition had orders for paroxetine and aripiprazole, but the consent form did not document dose, frequency, dx, targeted behavior, or discussion of risks and benefits. The DON and regional nurse consultant stated they expected those details to be included on the consent forms.
A facility failed to ensure that residents using bedside meds had been assessed for safe self-administration and had physician orders authorizing it. Surveyors observed a resident with COPD independently using nebulizer treatments after staff set them up, another resident with COPD and legal blindness using a nebulizer without monitoring, and two other residents with mouthwash and topical cream at bedside. Records showed intact cognition for several residents, but no valid self-administration assessments or physician orders supporting bedside use.
A resident with intact cognition and depression was started on antipsychotic medications without a documented diagnosis or clear indication on the orders, and the consent forms left the condition and alternatives blank. The care plan did not identify the resident’s behaviors or include nonpharmacological interventions, even though records showed agitation, combativeness, yelling, name calling, and other disruptive behaviors. Staff interviews confirmed the antipsychotics were expected to have a diagnosis and that care plans should reflect behaviors and interventions, consistent with the facility’s psychotropic medication policy.
Failure to Notify Ombudsman of Resident Discharge: A resident was discharged to another facility, but there was no documentation that the Office of State Long-Term Ombudsman was notified. The SSD stated she did not complete the notification and thought the administrator had done it, while the administrator said she was not responsible for the notification and did not know who oversaw it. The facility policy required reporting the discharge/transfer and uploading the Notice of Discharge form for the Ombudsman Program.
Inaccurate PASRR Coding on MDS Assessments: The facility failed to accurately code MDS A1500 for two residents with mental health diagnoses and PASRR findings. One resident had a Level II PASRR tied to bipolar disorder and other psychiatric diagnoses, and another resident had major depressive disorder, yet both MDS assessments were marked "No" for serious mental illness or related condition. The MDS/RN acknowledged the coding error for one resident and confirmed the other resident should have been coded "Yes."
PASRR Screening Not Completed or Resubmitted for Residents With Mental Health and Antipsychotic Medication Changes: A resident with major depressive disorder did not receive a required Level II PASRR after the diagnosis was identified, and another resident’s PASRR Level I was not resubmitted after antipsychotic medications were started and changed without documented supporting diagnosis. Staff stated the PASRR process was usually reviewed on admission and that a new screening should be submitted when a resident is started on a new psychotropic or antipsychotic medication or is diagnosed with a serious mental illness.
A resident had seven blood glucose readings over 400 mg/dL, but six of the elevated results were not reported to the physician. The resident’s BG checks and sliding scale insulin orders did not include parameters for notifying the MD, and staff interviews showed differing expectations about using order parameters versus protocol/standing orders. The facility’s protocol orders stated the MD should be contacted for BG less than 60 mg/dL or greater than 400 mg/dL unless otherwise specified.
Medication error rate exceeded 5% after surveyors observed two errors: an LPN left a lidocaine patch on a resident’s lower back after it should have been removed, and another LPN gave sucralfate without recognizing it was ordered before the noon meal. The MAR showed the patch had been documented as removed when it was still present, and staff interviews confirmed medications were expected to be given within the ordered time frame and before-meal meds before meals.
The facility failed to properly store and label medications and biologicals. Influenza vaccines were kept in a second medication-room refrigerator that had no thermometer and was not temperature monitored, even though staff confirmed the vaccines were stored there and the refrigerator had also been used for specimens and overflow meds. In addition, two bedside glucometer test strip containers in residents' rooms were not dated when opened, despite staff and manufacturer instructions indicating the strips expire after opening and the opening date should be recorded.
Meal Preferences Not Honored: An LPN read meal options to a resident who said he did not want fish and requested a hamburger, but he was later served fish instead and left the dining room without eating. His care plan, meal ticket, and RD notes documented no fish, no chicken, and no whole/chunked tomatoes, and interviews confirmed staff knew his preferences and that substitute menu items were available.
A resident with chronic kidney disease and other health issues suffered an acute kidney injury after receiving an incorrect dose of furosemide for five days. The error occurred due to a failure to discontinue a previous medication order, resulting in the resident receiving a total of 200 mg daily instead of the prescribed 160 mg. The oversight was discovered during a cardiology appointment, where increased creatinine levels and significant weight loss were noted.
The facility failed to maintain resident dignity by not covering urinary catheter bags in common areas. Observations showed three residents with uncovered catheter bags containing visible urine in the dining and activity areas. Interviews revealed staff were unaware of a policy requiring covers, although the facility had them available. The DON expected catheter bags to be covered when residents were outside their rooms.
The facility failed to ensure accountability for fentanyl patches for three residents, as patches were frequently unaccounted for and not documented properly. Despite standard practice requiring verification of patch placement each shift, this was not consistently done. The facility's policy required documentation and verification by two nurses for controlled substances, which was not adhered to, leading to the deficiency.
The facility failed to remove expired medications from the storage room. Observations revealed expired Hepatitis B and influenza vaccines in the locked refrigerator. The DON stated that the medication room should be checked monthly for outdated supplies, but there was no documented verification of this task. The facility's policy required expired medications to be removed and destroyed, which was not followed.
The provider failed to ensure consistent and accurate oral care for three residents, leading to significant plaque buildup and inadequate hygiene. CNAs documented oral care as completed without verifying it, and the facility lacked a policy for oral care, contributing to the inconsistency.
Failure to Maintain Safe Bed Systems and Prevent Accidents
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe bed environment free from entrapment hazards and to provide adequate supervision and accident prevention for multiple residents. Surveyors observed that several residents had loose side rails or grab bars and mattresses that were not secured or properly fitted, creating gaps between the rails, mattress, and bedframe. One resident’s bilateral side rails could move away from the bed one to two inches, and there was a five‑inch gap between the top of his mattress and the headboard. Another resident, who was legally blind and had previously fallen out of bed during a dream and sustained a brain bleed, had a left side rail that could move three inches away from the mattress; he reported telling a CNA and his daughter about the loose rail about a week earlier. A third resident used bilateral side rails for bed mobility; her right rail could move two to three inches away from the bed, the openings within the rails measured three and one‑half inches wide by 13 inches high, and there was a seven‑inch gap between the foot of her mattress and the footboard. Surveyors also found that the facility’s entrapment assessments and maintenance audits were incomplete or inaccurately documented. Review of the maintenance logbook for side rail inspections from January through April showed that only zone 1 (the opening within the side rail) was consistently assessed, while the other six FDA‑defined entrapment zones were often marked as not applicable, including zone 7 (the space between the mattress and headboard or footboard) even for residents without bed rails. In some months, all seven zones were documented as not applicable for numerous residents known to have side rails, and some residents with side rails were not included in the audits at all. The DON was unsure if there was a specific entrapment assessment policy and believed maintenance handled these assessments, while also acknowledging missing documentation for side rail assessments, consents, and physician orders, and that some side rails were installed without proper documentation. Additional deficiencies related to accident prevention and supervision were identified in several facility‑reported incidents. One resident with a history of stroke and left‑sided weakness fell from his bed while trying to remove his socks after a CNA left his bed at waist height; his care plan at that time did not specify a required bed height, and he was later diagnosed with a minor closed head injury and abrasions. Another resident, care planned to require two staff for transfers and use of a sit‑to‑stand lift, was transferred by a single contracted CNA using a sling that was too small and the wrong hook, causing back pain; the resident and his family reported that he was often transferred by only one staff member despite the care plan. A cognitively impaired resident at risk for elopement exited through a door whose alarm had been deactivated during daytime hours so visitors could enter and exit, walked outside in very cold weather, and re‑entered through another door after about 15 minutes. A further resident, on anticoagulant therapy, fell while transferring herself to the bathroom and hit her head; she had fallen 11 times in 30 days, and the provider failed to implement, review, and revise interventions to reduce her fall risk. These events collectively demonstrate failures to follow care plans, maintain environmental safety devices such as alarms and bed systems, and provide adequate supervision to prevent accidents. The surveyors determined that these failures, particularly the unsecured side rails and unassessed mattress gaps, created a risk for entrapment injury or harm and issued an Immediate Jeopardy finding under F689 related to accident hazards and supervision. Observations throughout the building confirmed multiple safety concerns with side rail installation, maintenance, and bed zone assessments, including loose rails and significant gaps between mattresses and headboards or footboards. Facility leadership and maintenance staff acknowledged that gaps between mattresses and bed ends and loose side rails posed a risk for entrapment and injury, and that entrapment zone measurements and assessments had not been consistently completed according to FDA guidance and facility policy.
Failure to Protect Resident from Sexual Abuse and Report Allegation
Penalty
Summary
The facility failed to protect a resident’s right to be free from sexual abuse when a contracted travel CNA touched the resident in a private area without his consent. The resident reported that at about 6:00 a.m., he woke up and found the CNA’s hands inside his pants. He stated that when he confronted the CNA, the CNA said he was trying to see if the resident was wet, and the resident told him to get out of the room. The resident said the CNA did not explain anything and that the contact made him feel cheap. The resident involved had diagnoses including dementia, unspecified psychosis not due to a substance or known physiological condition, insomnia, and anxiety disorder. His care plan indicated he was independent with toileting and normally used a urinal at night, and his quarterly MDS assessment showed a BIMS score of 13, indicating intact cognition. He told staff he was awake for early morning blood sugar checks or lab draws, but not for bathroom assistance, and he did not normally get checked for incontinence at night. Staff did not respond to the allegation in a timely or complete manner. One RN heard the resident’s report but did not notify the DON, even though she knew the facility’s process required escalation. Another RN spoke with the CNA but did not report the allegation further and stated she did not know the reporting timeframe. The DON and ADON were not informed until later that morning, and the administrator stated she did not contact law enforcement because she believed reporting would wait until the facility determined whether abuse occurred. At the time of the surveyor’s findings, no facility interviews with the resident, other residents, or staff had been initiated to investigate the allegation further.
Significant Medication Errors With Time-Sensitive Parkinson’s Medications and Incorrect Insulin Dose
Penalty
Summary
Residents were not free from significant medication errors. One resident with Parkinson’s disease and intact cognition had physician-ordered carbidopa/levodopa through a PEG tube every four hours and clonazepam for tremors, but the medication administration record showed multiple late administrations of both medications over the review period, along with one missed documented dose of carbidopa/levodopa. The resident was observed with tremors, soft speech, slow speech, and repeated tapping of his right foot, and he reported that when his medications were late he developed sweating, worse tremors and jerking movements, and difficulty using his urinal because of the increased movements. The resident also stated that his medications were often late, especially at night. The resident’s physician and the consultant pharmacist both stated that carbidopa/levodopa and clonazepam were to be given on schedule, with the physician identifying late or missed doses as significant medication errors. The physician also stated that the timing of these medications was based on the resident’s symptoms and that inconsistent administration could affect interpretation of his clonazepam gradual dose reduction. Facility leadership acknowledged that the resident’s medications were expected to be administered as scheduled and that late administration could alter the outcome of the gradual dose reduction attempt. A second resident with type 2 diabetes and intact cognition received an incorrect dose of Humalog insulin after an LPN entered the roommate’s blood sugar value into the resident’s EMR. The resident’s actual blood sugar was 122, which did not require insulin, but the LPN documented the roommate’s blood sugar of 258 and administered 7 units of Humalog based on that incorrect value. The LPN stated she was rushing while working with an RN in training and realized immediately that she had given insulin based on the wrong resident’s blood sugar. The resident’s physician, daughter, and DON were notified, and the resident’s blood sugars were monitored afterward. The consultant pharmacist stated that giving 7 units of insulin when the blood sugar was 122 could be considered a significant medication error.
Systemic Administrative and Nursing Leadership Failures Affecting Resident Care and Services
Penalty
Summary
Administrator A and DON B failed to operate and administer the facility in a manner that ensured quality of life and overall well-being for all 45 residents. Surveyors, through observation, interview, record review, policy review, and job description review over multiple days, identified a widespread system breakdown in ensuring that services met professional standards. Deficient areas included resident dignity, informed decision-making for psychotropic medications, resident self-administration of medications, honoring resident meal choices and preferences, responding to resident concerns raised in resident council meetings, protecting resident health information, informing residents how to file grievances, and handling allegations of resident abuse. Additional failures involved obtaining and documenting consent and diagnoses for psychotropic medications, timely reporting of allegations, and providing Ombudsman reports upon discharge. Further findings showed failures in clinical and regulatory processes, including inaccurate MDS assessments and PASSR evaluations, not refiling PASSR when residents had new diagnoses, and not developing resident-specific baseline care plans within 48 hours of admission or updating care plans as needed. The facility did not consistently notify physicians of residents' increased blood sugar levels and did not adequately address accident hazards related to bed side rails. There were issues with nebulizer and nasal cannula cleaning and storage, bed siderail assessments, orders and consent, call light response times, controlled substance accountability, medication errors, and storage of drugs and biologicals. Administrator A confirmed responsibility for daily operations and acknowledged frustration with siderail issues, while job descriptions for both the administrator and DON documented their responsibility for ensuring regulatory compliance and quality care, which was not achieved in these areas.
Confidential Resident Census Information Left in Public View
Penalty
Summary
The provider failed to ensure residents' rights to privacy and confidentiality of protected health information were protected when a facility census report containing resident private information was left in a hanging file organizer near the nurse's desk in an area accessible to anyone passing by. The report included resident names, admission dates, and payer sources, and it was not stored in a secure location. During interview, the administrator acknowledged that the document contained confidential information and was in an area accessible to the public, agreeing that this was a violation of resident confidentiality. Facility policy also stated that resident medical and billing records must be kept confidential and that protected health information should not be in the public viewing area.
Failure of Governing Body to Ensure Safe Facility Operations
Penalty
Summary
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. Survey findings from 4/21/26 through 4/23/26 and 4/27/26 through 4/29/26 showed that administrator A and DON B did not ensure management, safety, quality of life, and overall well-being for all residents. The report describes a widespread system breakdown involving resident dignity, informed decisions for psychotropic medications, self-administration of medications, meal choices and preferences, responses to resident concerns after resident council meetings, health information security, grievance filing, allegations of abuse, consent and diagnoses for psychotropic medications, timely reporting of allegations, Ombudsman reports upon discharge, accurate MDS and PASSR assessments, PASSR refiling after new diagnoses, baseline care plans within 48 hours of admission, care plan updates, physician notification of increased blood sugar levels, bed rail hazards, nebulizer and nasal cannula cleaning and storage, bed siderail assessments, orders and consent, call light wait times, controlled substance accountability, medication errors, and storage of drugs and biologicals. During interview, administrator A stated that when she returned to the position she was told by corporate staff that there were serious issues to work on and that corporate consultants should be used for help. She reported that multiple consultants were involved, including social services, dietary, registered dietitian, activities, regional nurse, administrator consultant, area administrators, and the MDS coordinator consultant, with weekly check-ins and standup meetings. The provider job descriptions reviewed stated that the Administrator is responsible for overall direction of facility operations and ensuring compliance with federal, state, and local regulations, and that the DON is responsible for the planning, development, and overall operation of the Nursing Department to ensure quality care 24 hours a day.
QAPI Program Did Not Identify or Monitor Key Quality Deficiencies
Penalty
Summary
The facility failed to ensure its QAPI program identified and corrected quality deficiencies when they occurred throughout the facility, and it did not have performance improvement projects thoroughly identified, implemented, or monitored for several areas affecting resident care and safety. During interview, the administrator stated she served as the QAPI coordinator and that department managers conducted their own audits, which she reviewed and consolidated for QAPI discussion. She also stated the QAPI committee reviewed reports and created PIP teams when resident care, quality of life, or safety issues were identified, but she confirmed that siderails, incident reporting, medication administration and storage, and baseline care plans were not currently identified as concerns for review and monitoring. The provider's undated QAPI plan stated that the QAPI Steering Committee would oversee the program and that corrective action plans or PIPs would be implemented when the need was identified. The plan listed multiple departments and leadership roles on the committee and referenced several regulatory tags, but the interview and plan review showed that the committee had not identified the cited areas of non-compliance for monitoring. The administrator also stated the facility relied on maintenance to complete siderail inspections using an FDA grid system, and that this system did not identify 4.75 inches as a maximum opening height for the siderail issue noted by surveyors.
Failure to Honor Resident Bathing and Undressing Preferences
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to dignity, respect, and self-determination regarding bathing and undressing practices. One resident reported in a facility reported incident that on his bath days, a CNA undressed him in his room, covered him with a blanket, and transported him through the hallway to the shower room, despite his stated preference to undress in the shower room. During a later interview, this resident stated that the CNA continued this practice, that it made him uncomfortable, and that it happened all the time. The DON stated that the bathing protocol was to follow each resident’s preference for where to undress, and that the CNA had been informed of this resident’s preference. The resident’s care plan documented his need for assistance with dressing but did not include his specific bathing or undressing location preferences. Additional interviews showed that this practice extended to other residents and was not individualized based on resident choice. The CNA acknowledged awareness of the resident’s preference but stated that all residents were undressed in the shower room, while another CNA described a typical routine in which residents with limited mobility who required a mechanical lift were undressed in their rooms, covered with a blanket, and then transported to the shower room. Another resident reported seeing the first resident transported to the shower room covered only by a blanket and stated that the CNA did not ask where he preferred to undress, instead beginning to undress him after announcing it was time for a bath. A third resident stated that the same CNA transferred him from bed to a chair, covered him with a white sheet, and took him to the tub room without asking his preferences, and that he had seen other residents transported in the same manner. These practices conflicted with the facility’s Resident Dignity & Privacy Policy, which required staff to groom and dress residents according to their preferences and to maintain privacy during care.
Failure to Timely Report and Investigate Allegations of Sexual and Financial Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report and initiate required investigations into two separate allegations of abuse, including sexual and possible financial abuse. One resident reported that at approximately 6:00 a.m. a contracted travel CNA placed hands down his pants while he was in bed, allegedly to check if he was wet, which the resident described as groping that made him feel cheap. The resident stated he typically did not receive nighttime incontinence checks, as he used a urinal and was usually only awakened for early morning blood sugar checks or lab draws. He reported this incident to two RNs, one of whom acknowledged that it was not appropriate for staff to put their hands down a resident’s pants to check incontinence products. Despite this, the nurses who received the allegation did not immediately report it to the DON, administrator, or state agency as required by facility policy and federal guidelines. One RN spoke with the contracted travel CNA to “educate” her but did not notify anyone else and did not know the required reporting time frame. Another RN, who was aware of the process and the two-hour reporting requirement to the state health department, also failed to promptly report the allegation to the DON or administrator, resulting in a delay until late morning before leadership became aware. At the time leadership was notified, the allegation had not yet been investigated, and law enforcement and the ombudsman had not been contacted, even though the allegation involved possible sexual abuse. A second deficiency arose when a resident’s family member reported concerns of suspected financial abuse to the social services designee, who then informed the administrator. Instead of treating this as an abuse allegation requiring reporting and investigation under the facility’s abuse and neglect policy, the administrator did not report it to the state health department, citing a lack of detailed information. The social services designee and administrator only provided the family with contact information for external agencies such as the state’s attorney and adult protective services. The facility’s own policy required that all allegations and suspicions of abuse, including misappropriation of property and exploitation, be immediately reported to the administrator or designee, investigated by the administrator or designee, and reported to the state agency within two hours, but these procedures were not followed for either the sexual abuse allegation or the suspected financial abuse concern.
Failure to Complete and Individualize Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and complete individualized baseline care plans within 48 hours of admission that contained the minimum healthcare information necessary to properly care for multiple residents, and to ensure these plans were reviewed with and offered to residents or their representatives. Record review showed that one resident admitted on 9/25/25 had a signed baseline care plan that lacked documentation of required assistance levels for transfers, bed mobility, bathing, dressing, toileting, eating, and did not include the physician-ordered diet. Another resident’s baseline care plan, last revised on 1/9/26, was signed but undated and similarly omitted the level of assistance needed for transfers, bed mobility, bathing, dressing, toileting, and eating. A third resident admitted on a specified date had no baseline care plan at all, and a fourth resident’s baseline care plan, uploaded on 12/19/25 and signed but undated, did not indicate how the resident transferred, walked, whether assistive devices were required, or the amount of assistance needed for dressing or toileting. Additional record reviews revealed that another resident admitted on a specified date had no baseline care plan in the EMR, and a further resident’s baseline care plan dated 4/5/26 did not specify how she transferred between surfaces, her diet, or the specific physician-ordered rehabilitation therapies. Interviews with the regional nurse consultant confirmed that two residents did not have individualized baseline care plans completed and that the facility likely did not have signed baseline care plans or documentation that copies were provided to residents or their representatives. An LPN stated that nurses initiate baseline care plans during admission and that all nurses and leadership can update them, and the MDS/RN acknowledged that staff may not know how to provide care if care plans are not resident-specific and completed, and confirmed that two residents’ baseline care plans, although reviewed with their representatives, were not personalized with specific care information. Policy review showed that the facility’s care plan policy required baseline care plans to be started on the first day of admission, completed within 48 hours, and to include minimum healthcare information such as initial goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendations, which was not consistently done.
Failure to Maintain Accurate, Resident-Specific Care Plans for Medications and Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to ensure resident care plans were reviewed and revised to reflect current, resident-specific care needs as required. For one resident with moderately impaired cognition and multiple diagnoses including diabetes, Parkinson’s disease, Alzheimer’s disease, dementia, major depressive disorder, anxiety, and orthostatic hypotension, the care plan dated 4/5/26 did not identify how the resident transferred between surfaces, did not specify her diet, and did not list the specific rehabilitation therapies ordered by the physician. This omission meant key aspects of her daily care and ordered services were not captured in the individualized care plan. Another resident with intact cognition and a diagnosis of depression had physician orders for sertraline for depression and olanzapine for behaviors and poor mood, but the care plan did not identify that she was receiving an antipsychotic medication, did not address her documented behaviors, and did not include any non‑pharmacological interventions for those behaviors. Progress notes over several weeks documented repeated episodes of agitation, combativeness, yelling, name‑calling, ripping papers, attempting to pinch another resident, and spitting at staff, yet these behaviors and related interventions were not incorporated into the care plan. The only psychotropic use noted in her care plan was within a fall‑risk focus area, without target symptoms or non‑pharmacological strategies. Two additional residents with moderately impaired cognition had care plans that inaccurately identified a focus area of potential for bruising and hemorrhage due to anticoagulant use, even though one was receiving antiplatelet medications (clopidogrel and aspirin) and had never been on an anticoagulant, and the other was only receiving aspirin and had no anticoagulant ordered. Interviews with CNAs indicated they relied on pocket care plans and the Kardex to determine residents’ care needs and that pocket care plans were sometimes not up to date. The MDS nurse and an LPN confirmed that care plans were expected to be accurate, resident‑specific, and to include antipsychotic use and behavioral interventions when applicable, and acknowledged that the care plans for these residents were not updated to reflect their actual medication regimens and behavioral needs, contrary to the facility’s psychotropic medication and care plan policies.
Delayed Call Light Response and Ineffective Grievance Process
Penalty
Summary
The facility failed to ensure prompt response to call lights and timely provision of needed cares and services for four residents identified in the report. One resident stated she sometimes waited an hour for staff to come help her in her room, including assistance with repositioning and incontinent care, and said she would remain soaking wet with burning in her peri-area until help arrived. Another resident reported that staff did not answer call lights, that she had to wait after using the bathroom because she could not put on a new incontinent product by herself, and that she had sat on the toilet for 25 minutes waiting for staff. A resident council meeting also documented complaints from two residents that call light response times were 30 minutes and 45 minutes. Staff interviews showed that the expected response time was much shorter than what residents reported. An LPN and a CNA each stated call lights should be answered in no more than five minutes, and the DON stated residents should not wait longer than five to ten minutes. The AD said the call light delays had been a consistent concern and described seeing a resident wait 15 to 20 minutes with the call light on before staff arrived. The administrator acknowledged that call light wait time grievances were a trend and that audits had been increased, while the SSD also identified extended call light wait times as a grievance trend. Record review supported the residents’ reports of delayed response times. The facility’s call light system did not track location or timing information for activations or response times. Call light audits from November 2025 through April 2026 included multiple response times over five minutes, including 10 minutes and 37 seconds, 17 minutes and 32 seconds, and 36 minutes and 16 seconds, with some required audits missing. Resident council minutes from October 2025 through March 2026 repeatedly documented concerns about call light wait times. The grievance review showed that 9 of 44 grievances were related to long wait times, and the grievance process was not effective because residents did not know how to file grievances, where forms were located, or how to file anonymously. The grievance forms were kept in a wall organizer by the nurses station that the SSD and administrator believed was not accessible to residents in wheelchairs, there was no drop box for anonymous submission, and several grievance records lacked documentation of notification, written communication preference, or satisfaction with the resolution.
Improper Storage and Cleaning of Oxygen and Nebulizer Equipment
Penalty
Summary
Infection control practices were not followed for residents using oxygen and nebulizer equipment. For one resident who used oxygen at night, surveyors observed the dated nasal cannula and tubing draped over the oxygen concentrator with the cannula touching the floor, and there was no bag attached to the concentrator for storage when not in use. On a later observation, the same resident’s oxygen tubing and nasal cannula were again hanging over the concentrator with the cannula lying on the floor. A CNA stated the cannula should not touch the floor, confirmed there was no bag on the concentrator, and discarded the tubing and cannula. An LPN stated nasal cannulas and oxygen tubing should be stored in a mesh bag when not in use, and the DON stated oxygen tubing should be placed in mesh bags on the concentrators and that tubing and cannulas observed on the floor should be thrown away and replaced. Two residents who used nebulizers also had equipment left assembled and not cleaned after use. One resident with COPD and intact cognition had a nebulizer machine and mask on her over-bed table, with clear liquid in the medication chamber during one observation and a hazy film inside the chamber during another. The resident stated nurses brought in the medication, set up the nebulizer, and left the room, and that the nurses did not rinse out the nebulizer mask after use but replaced the mask every few days. Another resident with COPD, legal blindness, and intact cognition had an assembled nebulizer mask lying on his bedside table and his oxygen cannula coiled and stuffed under the handle of the oxygen concentrator, with no bag attached for storage. On a later observation, his nebulizer mask was still assembled on the bedside table and his oxygen cannula remained rolled up under the concentrator handle. Review of the facility policies showed that nasal cannulas should be stored in a plastic bag when not in use and changed weekly and as needed. The Oral Inhalation policy directed staff to disconnect nebulizer parts when treatment was complete, rinse and disinfect the equipment, allow it to air dry, and store it in a plastic bag when completely dry. The budesonide manufacturer’s instructions stated the nebulizer chamber should be cleaned after every administration. An LPN stated she would set up one resident’s nebulizer treatment and later return to rinse the mask and air dry it on a paper towel until the next treatment, while the resident would place the mask on top of the nebulizer machine after use.
Side Rail Consent, Order, Evaluation, and Entrapment Assessment Deficiencies
Penalty
Summary
The facility failed to ensure informed consents for side rails were obtained before side rails were installed for seven sampled residents, physician orders were obtained before side rails were installed for 12 sampled residents, alternatives to side rails were attempted before installation for 21 sampled residents, and entrapment zone assessments were completed for 23 sampled residents who had side rails on their beds. The provider’s policy stated that bed rails were to be evaluated for appropriate placement, that the nurse was to complete the Side Rail/Other Devices Evaluation before implementation, that physician orders should not be obtained until prior interventions were discussed and documented, and that the Entrapment Zone Review Form was to be completed upon placement of rails and with changes of mattress. Maintenance logbook review for January through April 2026 showed inconsistent entrapment zone documentation. In some months only zone 1 was assessed and the remaining zones were marked not applicable, while in other months all seven zones were marked passed or not applicable. Several residents were documented as not applicable for all seven zones in April 2026, and some residents with side rails were not included on the April audit. There were also no documented entrapment assessments for zone 7 for residents without a bed rail. Maintenance staff and the DON acknowledged gaps in documentation and stated that loose side rails and mattress gaps posed a risk for injury and entrapment. Specific resident records showed multiple examples of missing or late documentation and side rails installed before required steps were completed. One resident had bilateral side rails installed before the maintenance record reflected installation, with consent and physician order obtained later. Another resident had bilateral side rails on the bed but no physician order and no documented alternatives before implementation. Other residents had side rails installed without a completed evaluation, without a specific physician order, or with consent forms that did not clearly indicate consent or refusal. Several residents had side rails installed before the Side Rail/Other Devices Evaluation was completed, and some evaluations documented no alternatives or incomplete alternatives. Observations also identified loose side rails, openings within side rails, and gaps between mattresses and headboards or footboards on several beds.
Inaccurate Documentation and Handling of Fentanyl Transdermal Patches
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and complete documentation and handling of fentanyl transdermal patches for a hospice resident, as required by policy and controlled substance procedures. The resident was admitted on hospice services and had physician orders for escalating doses of fentanyl patches, including 12 mcg/hr, 25 mcg/hr, 37 mcg/hr, and later 50 mcg/hr, with changes every 72 hours. The resident had liver disease and scratched frequently. On multiple occasions, fentanyl patches applied to the resident were later found to be missing and could not be located despite searches by nursing and laundry staff. The resident’s family member reported being present when a patch was applied and stated he had been notified twice that patches were missing, both times when the patches were placed on the resident’s chest. The facility’s own records and interviews showed inconsistent and incomplete documentation on the Transdermal Patch Controlled Drug Record. The record for April showed a fentanyl patch removed on one date without any date or time of destruction, and two 12 mcg patches applied on the same date that were never documented as destroyed. There were entries where a specific numbered 25 mcg patch was signed out for administration and then documented as destroyed at the same time, and another instance where a patch was documented as destroyed on the same day it was signed out, without clear correlation to removal from the resident. The missing fentanyl patch on one date was not documented on the Transdermal Patch Controlled Drug Record as missing. Additionally, a 50 mcg patch was documented as destroyed without a date or time, and another 50 mcg patch was documented as destroyed shortly after being signed out for administration. Interviews with staff confirmed confusion and deviation from the facility’s stated procedures. An LPN reported that the Transdermal Patch Controlled Drug Record was difficult to understand and described a practice where, if a second nurse was not available at night, used patches were placed in a medication cup and stored in a locked controlled medication drawer until day shift could witness destruction. The DON stated that fentanyl patches supplied by hospice did not come with a controlled medication tracking form, so the facility used the hospice-provided Transdermal Patch Controlled Drug Record to track removal from the cart and destruction. The DON expected accurate completion of this record, including date and time of removal from the cart and destruction, and acknowledged that the documentation suggested the patch being destroyed was the same one removed from the cart, as well as acknowledging missing dates and times of destruction. The facility’s Drug Diversion Prevention policy required placement checks every shift and two-nurse destruction with appropriate documentation, but the order for placement checks every shift was initially not entered, and the documentation on the controlled drug record did not consistently meet these requirements.
Incomplete Informed Consent for Psychotropic Medications
Penalty
Summary
The provider failed to ensure residents were fully informed and understood the risks, benefits, and alternatives related to psychotropic medications before they were given. For resident 33, who had an intact BIMS score of 13 and diagnoses including depression, the record showed orders for quetiapine 25 mg at bedtime and later olanzapine 5 mg at bedtime. The antipsychotic medication consent forms for both medications were signed by the resident representative and DON, but the forms left blank the sections for the reason the medications were ordered, the alternatives to the medications, and the check boxes for the antipsychotic warnings. The physician orders did not identify a diagnosis supporting either antipsychotic, and resident 33’s care plan did not identify antipsychotic use, mood alteration, or behaviors. For resident 3, who had an intact BIMS score of 15 and diagnoses including major depressive disorder, bipolar disorder with manic episode and psychotic features, schizophrenia, and insomnia, the record showed orders for paroxetine 10 mg and aripiprazole 15 mg at bedtime. The psychotropic medication consent form was signed by the resident and facility representative, but it did not document the doses, frequency, diagnosis, targeted behavior, or any discussion of risks and/or benefits. Those sections were left blank. The care plan identified psychoactive medication use and included interventions for monitoring behavior and adverse reactions, and it noted written consent for psychotropic medication, but the consent form itself lacked the required details. During interview, the DON stated she expected all antipsychotic medications to have a diagnosis supporting their use and expected the nurse receiving the order to confirm and obtain the diagnosis if it was missing. The DON and regional nurse consultant also stated they expected the medication consent form to include the doses, frequency, diagnosis, targeted behavior, and documentation that risks and/or benefits were discussed with the resident or representative. The facility policy stated informed consent for psychotropic medications would be obtained at initiation and for any dose increases, and that the black box warning for antipsychotics would be included on the informed consent.
Bedside Medication Self-Administration Without Required Assessment or Order
Penalty
Summary
The facility failed to ensure that residents who were receiving medications at bedside had been assessed for safe self-administration and had a physician's order authorizing self-administration. Surveyors observed multiple residents with medications or medication-related items left at the bedside, including nebulizer treatments, mouthwash, cough drops, and topical creams, without documentation that they had been evaluated and approved to self-administer those medications. One resident with COPD and intact cognition had a nebulizer, mask, and medication chamber at the bedside. Staff were observed bringing in nebulizer medication, setting up the treatment, and leaving the resident to complete it independently. The resident stated nurses brought the medication, set up the nebulizer, and returned after the treatment. The record showed physician orders for nebulized budesonide, formoterol, and ipratropium/albuterol, but there was no medication self-administration assessment in the EMR and no physician order stating the resident could self-administer the nebulizer medications. An LPN later confirmed that this resident was the only resident who self-administered medications and stated that a self-administration assessment and physician order should have been completed before allowing it. Another resident with intact cognition, legal blindness, and COPD was observed using a nebulizer without staff present to monitor the administration. Her record showed a prior self-administration assessment that identified visual impairment as a disqualifying factor and another assessment indicating she did not want to self-administer medications. The physician order for nebulized ipratropium/albuterol did not state that she could self-administer. Two other residents also had medications at bedside: one had a cup with Biotene mouthwash that staff had left for use before meals, and another had a cup with topical menthol gel that staff believed the resident might apply herself. Both residents had intact cognition, but neither had a physician order to self-administer those medications, and their medication self-administration evaluations did not support bedside self-administration. Staff and leadership confirmed that no residents in the facility had been assessed or had physician orders to self-administer medications, despite bedside medication use being observed.
Psychotropic Medication Used Without Documented Diagnosis or Care Plan Support
Penalty
Summary
Unnecessary psychotropic medication use was identified for a resident who had intact cognition on a BIMS score of 13 and a diagnosis of depression. The resident was receiving sertraline for depression, and was later started on quetiapine 25 mg at bedtime and then olanzapine 5 mg at bedtime. The physician orders for both antipsychotics did not identify a diagnosis for the medications, and the antipsychotic consent forms listed the medications as being used for the resident’s mood or were left blank where the condition being treated should have been documented. The resident’s record showed behavioral concerns beginning after the antipsychotics were ordered, including agitation, combativeness with care, grabbing staff, kicking, hitting, scratching, pinching, ripping papers from the nurses’ desk, yelling, name calling, reaching to pinch another resident, and spitting at staff. However, the care plan did not support that the resident was on an antipsychotic medication, did not identify behaviors, and did not include nonpharmacological interventions for those behaviors. The care plan only referenced psychotropic medication in relation to fall risk and did not identify target symptoms for sertraline or interventions to address behaviors. Interviews with nursing staff showed they expected antipsychotic medications to be linked to a diagnosis and that care plans should reflect current resident needs, behaviors, and nonpharmacological interventions. The DON stated that when a medication is started after admission, the nurse receiving the order should confirm there is a diagnosis for the medication and contact the physician if there is not. The facility’s psychotropic medication policy stated psychotropic medications are to be used only when necessary to treat a specific condition after non-pharmacological interventions have been attempted, and that resident-specific behaviors, interventions attempted, and the resident’s response are to be addressed in the care plan and monitored.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The provider failed to ensure the Office of State Long-Term Ombudsman was notified when resident 54 was discharged from the facility to another facility. Record review showed the resident was discharged on 1/27/26, the PCP was notified of intent to discharge, discharge orders were received on 1/26/26, and the resident's representative signed the discharge summary on 1/27/26. However, there was no documentation that the Ombudsman was notified of the transfer. During interview, the Social Services Designee stated she did not complete the Ombudsman notifications and believed the administrator had done so. The administrator stated she was not responsible for notifying the Office of State Long-Term Ombudsman and did not identify who oversaw those notifications. The facility's revised Discharge and Transfer of Residents/Bed Hold Policy stated that for South Dakota, ombudsman are notified by reporting the discharge/transfer and uploading the Notice of Discharge form through the specified DHS Ombudsman Program link.
Inaccurate PASRR Coding on MDS Assessments
Penalty
Summary
The facility failed to ensure accurate MDS coding for the PASRR-related assessment items for two sampled residents. Resident 2 was admitted from another LTC facility with diagnoses including bipolar disorder, generalized anxiety disorder, adjustment disorder, and binge eating disorder. Her record included a Level II PASRR stating she was not exempt from Level II review and required the level of services provided by a Medicaid-certified swing bed to a NF due to her physical or mental conditions, yet her 3/4/26 comprehensive MDS coded A1500 as "No" to whether she was currently considered by the state Level II PASRR process to have serious mental illness, intellectual disability, or a related condition. Resident 40’s EMR showed a diagnosis of major depressive disorder, but the MDS also coded A1500 as "No," indicating the resident did not have a serious mental illness, intellectual disability, or related condition. During interview, the MDS/RN and SSD stated PASRRs were usually completed by hospital staff before admission and that they reviewed diagnoses and medications against the PASRR screening; the MDS/RN acknowledged resident 2’s A1500 had been coded inaccurately and confirmed resident 40 had a qualifying major depressive disorder upon admission, meaning A1500 should have been marked "Yes." The facility policy stated PASRR is a federal requirement for residents with SMI or ID/DD, and the RAI manual stated A1500 should be coded "Yes" when the resident had a PASRR Level II, with A1510 then indicating the reason.
PASRR Screening Not Completed or Resubmitted for Residents With Mental Health and Antipsychotic Medication Changes
Penalty
Summary
The provider failed to complete a Level II PASRR for one resident with a qualifying mental health diagnosis and failed to resubmit a Level I PASRR for another resident after an antipsychotic medication was started. Resident 40’s EMR showed a diagnosis of major depressive disorder documented on 6/17/24, but her 3/31/26 PASRR Level I screening did not indicate a confirmed or suspected mental illness diagnosis. No additional PASRR Level I screening was completed and no PASRR Level II was submitted to the state agencies for review. During interview, the SSD stated she did not complete a PASRR Level II for resident 40 and was not aware of the major depressive disorder diagnosis during the admission process. Resident 33 had a BIMS score of 13, indicating intact cognition, and her diagnoses included depression. She had a PASRR Level I screening before admission, but after being prescribed quetiapine 25 mg at bedtime on 3/6/26 and later changed to olanzapine 5 mg at bedtime on 3/29/26, there was no supported documentation of a diagnosis for the antipsychotic use. There was also no documentation that her PASRR Level I screening had been resubmitted after the antipsychotic medication was added. The MDS/RN and SSD stated that PASRRs were usually reviewed against diagnoses and medications on admission, and that a new PASRR Level I screening would be submitted if a resident was started on a new psychotropic or antipsychotic medication or diagnosed with serious mental illness, intellectual disability, or developmental disability; SSD stated she was not aware resident 33 had an antipsychotic added, and the MDS/RN acknowledged the medication change should have triggered a new PASRR screening.
Failure to Report Elevated Blood Glucose Results
Penalty
Summary
The nursing facility failed to ensure staff followed nursing professional standards of practice for notifying the physician of elevated blood glucose for one sampled resident. Review of the resident’s EMR showed that from 4/8/26 to 4/12/26 there were seven blood glucose results over 400 mg/dL, and six of those seven elevated results were not reported to the physician. The resident’s blood glucose checks had been started on 4/3/26 twice daily, but the orders did not include parameters for when to notify the physician. Review of the resident’s insulin orders also showed that the 4/13/26 sliding scale insulin orders did not include blood glucose parameters. During interview, an LPN stated she would contact the doctor based on order parameters, and if no parameters were present and the blood glucose was elevated or low, she would contact the DON and then the doctor’s office for further orders or instruction. The DON stated that if the ordering doctor did not give blood glucose parameters, nursing staff should use the protocol/standing orders. The MD stated she expected physicians ordering blood glucose and sliding scale insulin to include parameters for when staff should contact the doctor, and if not, staff should contact a doctor to ask for parameters; she also stated the protocol standing orders were acceptable guidance and that staff should contact a doctor if blood glucose was over 400 mg/dL. The facility’s Protocol Orders stated staff should contact the MD if blood glucose was less than 60 mg/dL or greater than 400 mg/dL unless otherwise specified.
Medication Error Rate Exceeded Due to Missed Patch Removal and Late Pre-Meal Sucralfate
Penalty
Summary
The provider failed to keep the medication error rate below 5 percent after surveyors observed two medication administration errors that resulted in a 7.41% error rate. One error involved resident 30, who had an order for a lidocaine 4% external patch to be applied to the lower back once daily and removed as scheduled. During observation, LPN KK applied a new patch and found that the prior patch, dated 4/27, was still on the resident’s lower back even though the MAR documented it as removed at 6:59 p.m. by LPN SS. LPN KK reviewed the order and stated lidocaine patches are usually applied for 12 hours and then removed, and she verified the patch had been documented as removed when it had not been removed from the resident. The second error involved resident 19, who had an order for sucralfate 1 gram before every meal and at bedtime for GERD. During medication administration observation, LPN KK prepared acetaminophen, a topical pain relief gel, and sucralfate, but administered the sucralfate without recognizing that it was due before the noon meal. LPN KK stated she did not realize the resident had a medication that was supposed to be given prior to the noon meal. Interviews with staff and the DON showed medications were expected to be given within one hour of the scheduled time, and medications ordered before meals were expected to be administered before the meal.
Improper Refrigerator Temperature Monitoring and Undated Glucose Test Strips
Penalty
Summary
The provider failed to ensure proper storage and labeling practices for medications and biologicals in the medication room. During observation and interview, two refrigerators were present in the room, and influenza vaccines were stored in the second refrigerator. RN D stated that the temperature of the second refrigerator was not monitored, and that it had been used for specimen storage and occasionally for overflow medications when the first refrigerator became too full. There was no thermometer in the second refrigerator, and LPN N verified that its temperature was not monitored even though influenza vaccines were stored there. The vaccine labels indicated they were to be stored between 36 and 46 degrees Fahrenheit, and the facility policy required refrigerated medications and biologicals to be maintained within that range with a thermometer for temperature monitoring. The provider also failed to date opened glucometer test strip containers in two residents' rooms. In resident 47's room, a partially empty bottle of glucometer test strips was observed without a date documenting when it had been opened. In resident 32's room, LPN N used a glucometer and glucose test strip from a bedside container that also had no opening date. LPN N stated she did not date glucose test strips when opened and relied on the manufacturer's expiration date, while the DON and regional nurse consultant stated the strips should be dated when opened because they expire before the manufacturer's expiration date. The manufacturer's instructions stated the test strips expire 3 months after first opening and that the first opening date should be written on the vial.
Meal Preferences Not Honored
Penalty
Summary
The facility failed to honor a resident's meal choice preferences during an observed noon meal. During observation, an LPN read the meal options aloud to the resident, who stated that he did not like the fish being served and wanted a hamburger instead. The LPN wrote on the resident's meal ticket and left the dining room, but the resident was later served fish. When the LPN passed by, the resident told his tablemate that he did not want fish, and the LPN responded that if he did not fill out his menu he would get what was being served. The resident then left the dining room a few moments later without eating the fish. Record review and interviews showed that the resident's preferences were documented in his care plan, meal ticket, and nutrition assessments as no fish, no chicken, and no whole or chunked tomatoes. The resident stated that staff kept bringing him fish despite his repeated requests and that the LPN had helped him request a hamburger, but fish was served instead. A family member confirmed that he did not like fish, chicken, or tomatoes and would leave the dining room hungry if served foods he did not like. The dietary manager and social services designee stated that substitute items were available and that staff should offer alternatives when a resident was unhappy with a meal, and the CNA and cook described checking meal tickets and updating preferences, but the resident's documented preferences were not followed during the observed meal.
Significant Medication Error Leads to Acute Kidney Injury
Penalty
Summary
The provider failed to ensure that a resident was free from significant medication errors, resulting in an acute kidney injury. The resident, who had diagnoses including congestive heart failure, chronic kidney disease, localized edema, and hypertension, experienced several changes in the frequency and dosage of furosemide, a diuretic medication. On a specific date, the physician ordered an increase in the resident's daily furosemide dose from 80 mg to 120 mg. However, after a cardiology appointment, the resident was supposed to restart oral furosemide at 80 mg twice daily, but the previous additional 40 mg daily dose was not discontinued, leading to the resident receiving an incorrect total dose of 200 mg daily for five days. The medication error was discovered during a cardiology appointment, where it was noted that the resident's creatinine level had increased, indicating impaired kidney function. The resident also experienced a weight loss of 13 pounds over the five days. The error was attributed to a transcription oversight, where the additional 40 mg dose was not discontinued in the medication administration record (MAR). The facility's process required the nursing staff to verify and confirm medication orders, but this step was not adequately followed, resulting in the administration of the incorrect dose. Interviews with facility staff, including the director of nursing and a registered pharmacist, revealed that the error occurred due to a lack of proper verification and discontinuation of the previous medication order. The pharmacy staff did not discontinue the 40 mg dose when the new order was entered, and the nursing staff failed to catch the error during the confirmation process. The resident, who had moderate cognitive impairment, required assistance with medication administration, further complicating the situation.
Failure to Cover Urinary Catheter Bags in Common Areas
Penalty
Summary
The deficiency involves the failure of the facility to preserve the dignity of three residents by not ensuring their urinary catheter bags were covered while they were in common areas. Observations revealed that one resident was seen wheeling himself in the hallway and seated in the dining area with his catheter bag uncovered and visible urine. Another resident was observed during lunch and later while playing bingo and watching TV, with her catheter bag uncovered and visible to other residents. A third resident was also seen in the dining area with his catheter bag uncovered and visible to others. Interviews with staff, including an LPN and an RN, indicated a lack of awareness of any policy requiring catheter bags to be covered. The RN later discovered that the facility did have catheter covers but was unsure why they were not used. The DON expressed that it was her expectation for catheter bags to be covered when residents were out of their rooms, highlighting a disconnect between expectations and practice.
Failure to Monitor and Document Fentanyl Patch Placement
Penalty
Summary
The provider failed to ensure the accountability of fentanyl patches for three of five sampled residents, specifically residents 8, 30, and 144. The issue was identified when a registered nurse reported being unable to locate a fentanyl patch on resident 144, which had been placed three days prior. Further investigation revealed that the nursing staff had been unable to locate resident 144's fentanyl patch on four other occasions. Interviews with the resident and his spouse did not provide clarity on the missing patches, and a housekeeper did not recall seeing any patches on the floor. A pain assessment indicated that the resident rated his pain as zero on a scale of zero to ten. The facility's controlled substance/narcotic record showed that on multiple occasions, the record was signed by only one nurse, and it was documented that the patches were missing or not found. Additionally, the placement verification of fentanyl patches for residents 8 and 30 was not entered into their medication administration records (MAR) until a month or more after the patches were ordered. Interviews with nursing staff revealed that checking the placement of fentanyl patches each shift was considered standard practice, yet this was not consistently documented or followed. The facility's Drug Diversion Prevention policy required that the placement of transdermal controlled substances be checked and documented every shift, and that removal and destruction of such patches require verification by two nurses. However, the facility did not adhere to these procedures, leading to the deficiency in monitoring and documenting the placement of fentanyl patches for the affected residents.
Expired Medications Not Removed from Storage
Penalty
Summary
The provider failed to ensure expired medications were removed from the medication storage room. During an observation, it was found that 23 Hepatitis B vaccines and three multi-dose vials of influenza vaccine were expired and still stored in the locked refrigerator. The assistant director of nursing (ADON) confirmed these findings. An interview with the director of nursing (DON) revealed that the medication room was supposed to be checked for outdated medications and supplies each month, a task assigned to the night shift. However, there was no documented verification that this task was completed. The DON expected expired medications to be removed and properly disposed of, as per the facility's policy. The facility's policy from January 2018 stated that all expired medications should be removed from the active supply and destroyed in the facility, regardless of the amount remaining. The expired medications were not removed, indicating a failure to adhere to this policy.
Inconsistent and Inaccurate Oral Care Documentation
Penalty
Summary
The provider failed to ensure consistent and accurate oral care for three of four sampled residents. Resident 2 had significant plaque buildup and reported not having his teeth brushed for approximately three days, despite documentation indicating oral care was completed. The CNA admitted to not assisting with oral care as documented. Resident 2's care plan indicated he required assistance with oral care due to decreased mobility, but this was not consistently provided. Similarly, Resident 3 had visible plaque buildup and reported not having his teeth brushed for a couple of days. The CNA documented oral care as completed without verifying it with the resident. Resident 3's care plan also required assistance with oral care, which was not adequately provided. Resident 4's toothbrush was dry, and the CNA claimed to have thrown away the used toothbrush, which was inconsistent with the observation of the dry toothbrush. Resident 4's care plan lacked specific interventions for oral care despite her decreased mobility and need for assistance. Interviews with the DON and RN revealed an expectation that oral care should be completed twice daily for all residents. However, the facility did not have a policy for oral care, contributing to the inconsistency in care and documentation. The lack of a structured policy and failure to adhere to care plans resulted in inadequate oral hygiene for the residents, as evidenced by the observations and interviews conducted during the survey.
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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 Watertown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jenkin's Living Center | 0.7 mi | ★★★★★ | 6 | 0 |
| Estelline Nursing And Care Center | 20.9 mi | ★★★★★ | 0 | 0 |
| Avantara Lake Norden | 22.9 mi | ★★★★★ | 2 | 1 |
| Avantara Clark City | 30.9 mi | ★★★★★ | 7 | 0 |
| Avantara Milbank | 31.1 mi | ★★★★★ | 12 | 0 |
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