Avantara Groton

In the surveyor’s words

From the most serious findings on record at Avantara Groton, in the surveyor’s own words.

• Actual harm, isolatedF578Nov 26, 2024

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

• Actual harm, isolatedF686Nov 4, 2021

  Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (16) who had developed a pressure ulcer while in the facility had: *Family and physician notified of the new pressure ulcer. *Obtained physician orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] *Interventions for prevention of the pressure ulcer updated in his care plan. *Weekly skin assessments and wound assessments completed. *Monthly pressure ulcer risk assessments completed. Findings include: 1. Observation on 11/2/21 at 11:38 a.m. […]

• No harm, potential for more than minimal, widespreadF655Dec 11, 2025

  Based on observation, interview, record review, and policy review, the provider failed to develop and implement a resident-centered baseline care plan within 48 hours of admission for four of five sampled residents (1, 3, 20, and 37) who were recently admitted .Findings include:1. Review of resident 3's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His 11/19/25 Brief Interview of Mental Status (BIMS) assessment score was 13, which indicated his cognition was intact. *A 3/31/25 progress note stated, A copy of his admission summary note was provided to [the] resident. Baseline care plan was reviewed with [the] resident. […]

• No harm, potential for more than minimal, patternF641Dec 11, 2025

  Based on observation, interview, record review, Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025 review, the provider failed to ensure five of five sampled residents' (4, 7, 8, 19, and 37) Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessments were accurately coded for the areas of weight loss, Pre-admission Screening and Resident Review (PASRR), insulin administration, and pneumococcal (pneumonia) vaccination status.Findings include:1. Interview on 12/9/25 at 4:10 p.m. […]

• No harm, potential for more than minimal, patternF761Dec 11, 2025

  Based on observation, interview, record review, and policy review, the provider failed to ensure medications for four of four sampled residents (18, 20, 23, and 34) with physician's orders for antifungal powder were labeled and stored according to the provider's policy. Findings include:1. Observation in resident 23's bathroom on 12/9/25 at 10:20 a.m. revealed:*One open bottle of Miconazole 2% powder (a medicated powder used to prevent fungal growth on skin) on the shelf. The bottle had resident 23's first name and last initial handwritten on it. There was no pharmacy label on that bottle.*The bathroom is shared between four residents. 2. Observation and interview on 12/10/25 at 2:42 p.m. […]