Deficiencies (last 3 years)
Deficiencies (over 3 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
142% worse than South Dakota average
South Dakota average: 3.3 deficiencies/year
Deficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 9
Dec 11, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, accurate assessments, care planning, medication administration, infection control, and safety measures including use of side rails.
Findings
The provider failed to ensure accurate documentation of residents' code status, accurate Minimum Data Set (MDS) assessments, timely development of baseline care plans, proper medication administration documentation, adherence to infection control practices, proper labeling and storage of medications, appropriate serving of pureed diets, and documented alternatives and risk/benefit review for use of bed rails.
Deficiencies (9)
| Description |
|---|
| Failed to ensure residents' code status (DNR/full code) was accurately documented in electronic medical records and physician orders. |
| Failed to ensure accurate coding of Minimum Data Set (MDS) assessments for weight loss, PASRR, insulin administration, and pneumococcal vaccination status. |
| Failed to develop and implement resident-centered baseline care plans within 48 hours of admission for sampled residents. |
| Failed to ensure medication administration documentation for antifungal powder was completed according to policy and that physician-ordered speech therapy was implemented. |
| Failed to document alternatives attempted and review risks and benefits with residents or representatives prior to use of bed rails. |
| Failed to ensure medications for antifungal powder were labeled and stored according to policy; multiple residents' powders were unlabeled and stored in shared bathrooms. |
| Failed to ensure proper hand hygiene and glove use by staff during meal service, including contamination risks from touching food with gloved hands. |
| Failed to ensure standard infection control practices including hand hygiene, use of personal protective equipment (PPE), and cleaning/disinfection of shower rooms between residents. |
| Failed to ensure pureed food was prepared and served according to policy, including use of broth instead of water for pureeing and measuring portions with appropriate scoops. |
Report Facts
Residents sampled for baseline care plan deficiency: 4
Residents sampled for code status documentation deficiency: 3
Residents sampled for MDS assessment deficiency: 5
Residents sampled for medication administration documentation deficiency: 4
Residents sampled for bed rail documentation deficiency: 2
Residents sampled for pureed diet deficiency: 2
Residents sampled for infection control deficiency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN I | Licensed Practical Nurse | Interviewed regarding code status documentation, baseline care plans, and side rail use |
| RN/MDS Coordinator E | Registered Nurse/Minimum Data Set Coordinator | Interviewed regarding MDS assessment accuracy and baseline care plans |
| Regional Nurse Consultant D | Regional Nurse Consultant | Interviewed regarding multiple deficiencies including code status, MDS, care plans, medication administration, infection control, and side rails |
| CNA L | Certified Nursing Assistant | Observed and interviewed regarding hand hygiene and infection control during meal service |
| CNA K | Certified Nursing Assistant | Observed and interviewed regarding infection control and shower cleaning |
| CNA P | Certified Nursing Assistant | Observed and interviewed regarding infection control and shower cleaning |
| CNA M | Certified Nursing Assistant | Interviewed regarding medication administration practices |
| Cook Q | Cook | Observed and interviewed regarding food preparation and glove use |
| Guest Services Aide/Cook R | Guest Services Aide/Cook | Observed and interviewed regarding food service and glove use |
| Certified Dietary Manager F | Certified Dietary Manager | Interviewed regarding pureed food preparation and serving |
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 26, 2024
Visit Reason
The inspection was conducted following a facility-reported incident regarding a resident's right to refuse a COVID-19 vaccination, which was allegedly not honored by staff.
Findings
The provider failed to ensure that one resident's right to refuse the COVID-19 vaccine was respected, resulting in the resident receiving the vaccine against her wishes. The staff member misread the consent form, leading to the error. Corrective actions including staff re-education and a facility-wide audit were implemented.
Complaint Details
The investigation was complaint-related, triggered by a facility-reported incident where a resident was vaccinated despite refusing the vaccine. The complaint was substantiated as the resident's rights were violated. The resident expressed frustration and the staff member responsible was suspended and re-educated.
Severity Breakdown
Level of Harm - Actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to honor one resident's right to refuse a COVID-19 vaccination, resulting in the resident receiving the vaccine against her wishes. | Level of Harm - Actual harm |
Report Facts
Residents affected: 1
Date of vaccination clinic: Oct 22, 2024
Date of survey completion: Nov 26, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Misread vaccine declination form and administered vaccine against resident's wishes. |
| DON B | Director of Nursing | Informed about the incident and worked with social services to conduct facility-wide audit. |
| Administrator A | Administrator | Participated in investigation and suspension of LPN D. |
| Social services designee C | Social Services Designee | Noticed resident upset, informed DON, and participated in follow-up actions. |
Inspection Report
Routine
Deficiencies: 5
Jul 31, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care plans, medication administration, infection prevention and control, and catheter care at Avantara Groton nursing home.
Findings
The provider failed to ensure resident care plans were updated to reflect enhanced barrier precautions for residents with wounds or indwelling devices. Medication administration errors were observed related to insulin pen priming. Infection control practices were deficient, including improper glove changes and hand hygiene during dressing changes and catheter care.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to revise resident care plans to reflect the need for Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling devices. | Level of Harm - Minimal harm or potential for actual harm |
| Medication error rate of 9.68% due to failure to prime insulin pen needles prior to administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to perform appropriate glove changes and hand hygiene during dressing change for a resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to place resident on Enhanced Barrier Precautions (EBP) and ensure signage and PPE availability. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure appropriate glove use, hand hygiene, and catheter care technique during foley catheter care. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 9.68
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Confirmed care plans were not updated to reflect Enhanced Barrier Precautions; involved in interviews regarding infection control and care plan deficiencies. |
| RN unit manager C | Registered Nurse Unit Manager | Observed performing dressing change with improper glove use; interviewed regarding infection control practices. |
| RN F | Registered Nurse | Observed administering insulin without priming pen needles; involved in medication administration deficiency. |
| CNA D | Certified Nursing Assistant | Observed performing foley catheter care with improper hand hygiene and glove use. |
| DOR G | Director of Rehabilitation | Observed in resident room without gown or gloves during care; interviewed about Enhanced Barrier Precautions. |
| Regional nurse consultant H | Regional Nurse Consultant | Interviewed regarding infection control deficiencies. |
| Registered nurse unit manager F | Registered Nurse Unit Manager | Interviewed regarding catheter care deficiencies and hand hygiene expectations. |
Inspection Report
Annual Inspection
Deficiencies: 9
Apr 14, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for the nursing home Avantara Groton.
Findings
The survey identified multiple deficiencies including failure to provide dignified care during resident transport, lack of notification for room changes, failure to support resident sleep schedules, untimely completion of Minimum Data Set assessments, absence of baseline care plans for new admissions, inadequate follow-up on suicidal ideation, failure to act on pharmacist medication recommendations, improper disposal of expired medications, and incomplete documentation of pneumonia vaccinations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to provide care in a considerate manner for two residents during transport, including pulling a resident backward in a shower chair without regard for dignity or safety. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to notify two residents of room and/or roommate changes prior to moving them. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to support the sleep schedule for one resident who was awakened early for medication administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to complete Minimum Data Set (MDS) assessments in a timely manner for five residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to create and implement baseline care plans within 48 hours for three newly admitted residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate follow-up interventions and documentation for one resident who expressed suicidal ideations. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure physician and director of nursing acted upon pharmacist's medication recommendations for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to dispose of expired medications in the automated dispensing cabinet. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to document administration or refusal of pneumococcal vaccination for two residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 13
Residents affected by dignity deficiency: 2
Residents affected by room change notification deficiency: 2
Residents affected by sleep schedule deficiency: 1
Residents affected by untimely MDS assessments: 5
Newly admitted residents without baseline care plans: 3
Residents affected by suicidal ideation follow-up deficiency: 1
Residents affected by pharmacist recommendation follow-up deficiency: 1
Expired medication types listed: 14
Residents affected by pneumonia vaccination documentation deficiency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA G | Certified Nursing Assistant | Named in dignity and safety deficiency for transporting resident 10 |
| COTA I | Certified Occupational Therapy Assistant | Named in dignity deficiency for interaction with resident 17 |
| LPN H | Licensed Practical Nurse | Mentioned in relation to resident 17 and resident 20 behavior and medication administration |
| SSD F | Social Services Director | Mentioned in relation to room change notification and suicidal ideation follow-up |
| DON B | Director of Nursing | Mentioned in multiple findings including dignity, medication follow-up, and vaccination documentation |
| ADM E | Administrator | Interviewed regarding dignity and communication policies |
| EPH A | Emergency Permit Holder | Interviewed regarding dignity and policy issues |
| QMA K | Qualified Medication Aide | Mentioned in medication administration timing for resident 5 |
| AD L | Activity Director | Mentioned in relation to missed activity evaluation for MDS |
| Regional Nurse Consultant D | Regional Nurse Consultant | Interviewed regarding policy on self-harm and suicidal ideation |
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