Avantara Watertown

In the surveyor’s words

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

• Immediate jeopardy, patternF689Apr 29, 2026

  A. Based on observation, interview, record review, and policy review, the provider failed to ensure resident safety regarding the side rails/grab bars and mattresses on the resident's beds were assessed for entrapment (trapped between the rail, mattress, or bedframe spaces) risk for three of three sampled residents (23, 35, and 48) who had loose side rails/grab bars on their beds and three of three sampled residents (23, 32, and 35) who had an unsecured mattress on their bed. Those failures put the identified residents at risk for entrapment injury or harm. Findings include: 1. Observation and interview on 4/22/26 at 10:31 a.m. with resident 35 in his room revealed his bilateral side rails could move away from his bed one to two inches. […]

• Immediate jeopardy, isolatedF600Apr 29, 2026

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

• Actual harm, isolatedF760Apr 29, 2026

  Based on observation, interview, record review, policy review, and manufacturer's instructions review, the provider failed to ensure residents were free from significant medication errors for one of one sampled resident (7) who was not administered his physician-ordered carbidopa/levodopa (a medication to treat Parkinsons disease; a progressive movement disorder) and clonazepam (a medication used to treat anxiety and tremors) according to the medications' administration schedules which resulted in increased tremors (shaking), muscle spasms (sudden, involuntary, and often painful contraction of one or more muscles), and anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), and for one of one sampled… […]

• Actual harm, isolatedF760Mar 6, 2025

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

• No harm, potential for more than minimal, widespreadF583Apr 29, 2026

  Based on observation, interview, and policy review, the provider failed to ensure all residents' right to privacy and confidentiality of protected health information (an individual's health, treatment, and payment information, also known as PHI) were protected related to a facility census document that was stored in an area accessible to anyone who passed by. Findings include:1.Observation on 4/27/26 at 11:35 a.m. near the nurse's desk revealed a hanging file organizer that contained a facility census report with resident private information, including name, admission date, and payer source. That report was not in a secure location and could have been accessed by anyone. 2. Interview on 4/27/26 at 11:42 a.m. […]