Inspection Reports for Avantara Watertown
415 4th Ave. NE, Watertown, SD 57201, Watertown, SD
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 6, 2025, identified a deficiency related to a medication error that resulted in acute kidney injury for one resident. Earlier inspections showed a pattern of medication management issues, including problems with fentanyl patch accountability and expired medications, as well as concerns about resident dignity and oral care documentation. Complaint investigations in December 2024 and March 2025 were substantiated, focusing on medication errors and controlled substance monitoring. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s inspection history indicates ongoing challenges with medication management, with corrective actions implemented after each finding.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% better than South Dakota average
South Dakota average: 3.3 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 6, 2025
Visit Reason
The inspection was conducted based on a complaint report from the South Dakota Department of Health regarding a significant medication error involving resident 1, who suffered an acute kidney injury after receiving an incorrect dose of medication for five consecutive days.
Complaint Details
Based on South Dakota Department of Health complaint report review, record review, and interview, the provider failed to ensure one resident was free from a significant medication error leading to acute kidney injury. The medication error was substantiated and considered past non-compliance after corrective actions were implemented.
Findings
The facility failed to ensure resident 1 was free from significant medication errors, resulting in administration of an additional 40 mg dose of furosemide daily for five days, which contributed to acute kidney injury. The error was due to a transcription oversight where the 40 mg dose was not discontinued after a medication order change. The facility implemented corrective actions including staff education, a double-check system for medication orders, and pharmacy re-education.
Deficiencies (1)
Failure to ensure residents are free from significant medication errors, resulting in resident 1 receiving an incorrect dose of furosemide for five days causing acute kidney injury.
Report Facts
Days medication error occurred: 5
Creatinine level increase: 1.48
Weight loss: 13
BIMS assessment score: 10
Medication doses: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse D | Registered Nurse | Administered medications on 3/6/25 with no errors identified and received education on medication order processing. |
| Administrator A | Administrator | Interviewed regarding resident 1's medication error and facility corrective actions. |
| Director of Nursing B | Director of Nursing | Interviewed regarding medication error; expected nurses to verify pending orders against physician's written orders. |
| Registered Pharmacist C | Pharmacy Manager | Managed pharmacy that received resident 1's medication order; confirmed the 40 mg dose was not discontinued and pharmacy staff was re-educated. |
| Licensed Practical Nurse E | Licensed Practical Nurse | Confirmed resident 1's pending order for furosemide 80 mg twice daily on 2/15/25 and received education after the medication error was identified. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 5, 2024
Visit Reason
The inspection was conducted following a South Dakota Department of Health Facility Reported Incident regarding missing fentanyl patches on residents, specifically focusing on the accountability and monitoring of controlled topical pain medication patches.
Complaint Details
The complaint involved missing fentanyl patches on residents 8, 30, and 144. The patches were not properly monitored or documented, leading to multiple instances of missing patches. The complaint was substantiated based on record reviews, interviews, and policy reviews.
Findings
The facility failed to ensure accountability of fentanyl patches by not monitoring and documenting patch placement for three of five sampled residents. Multiple missing patches were reported, and documentation and monitoring practices were found lacking. Education and monitoring improvements were implemented during the investigation.
Deficiencies (1)
Failed to ensure accountability of fentanyl patches by not monitoring and documenting placement for three of five sampled residents.
Report Facts
Residents affected: 3
Current residents receiving fentanyl patches: 4
Dates patches missing: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Interviewed regarding missing fentanyl patches and reporting expectations. |
| RN G | Registered Nurse | Reported missing fentanyl patch on resident 144. |
| ADON C | Assistant Director of Nursing | Reviewed controlled substance records and involved in interviews. |
| RN F | Registered Nurse | Interviewed about standard practice for checking fentanyl patch placement each shift. |
| LPN D | Licensed Practical Nurse | Interviewed about fentanyl patch placement verification and reporting. |
| DON B | Director of Nursing | Interviewed about responsibilities for monitoring controlled substance records and admission procedures. |
| RNC I | Regional Nurse Consultant | Interviewed about pharmacy changes and expectations for reporting missing patches. |
| LPN J | Licensed Practical Nurse | Documented missing patch on resident 144's MAR. |
| Housekeeper H | Interviewed about observations related to missing patches. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Dec 5, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident dignity, pharmaceutical services, medication storage, and controlled substance management.
Findings
The facility was found deficient in preserving resident dignity by not ensuring urinary catheter bags were covered in common areas, failing to monitor and document fentanyl patch placement for residents, and not removing expired medications from the medication storage room. These deficiencies posed minimal harm or potential for actual harm to some residents.
Deficiencies (3)
Failed to preserve the dignity of residents by not ensuring urinary catheter bags were covered while residents were in common areas.
Failed to ensure accountability of fentanyl patches by not monitoring and documenting placement for three of five sampled residents.
Failed to ensure expired medications were removed from the medication storage room.
Report Facts
Expired Hepatitis B vaccines: 23
Expired influenza vaccine vials: 3
Residents using fentanyl patches: 4
Missing fentanyl patch incidents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| D | Licensed Practical Nurse (LPN) | Interviewed regarding urinary catheter bag policy and fentanyl patch placement |
| F | Registered Nurse (RN) | Interviewed regarding urinary catheter bag covers and fentanyl patch monitoring |
| B | Director of Nursing (DON) | Interviewed regarding expectations for catheter bag covers and fentanyl patch monitoring |
| C | Assistant Director of Nursing (ADON) | Interviewed regarding fentanyl patch incidents and medication storage |
| A | Administrator | Interviewed regarding fentanyl patch monitoring and controlled substance record review |
| I | Regional Nurse Consultant (RNC) | Interviewed regarding pharmacy changes and fentanyl patch verification process |
| G | Registered Nurse (RN) | Reported missing fentanyl patch incident |
| J | Licensed Practical Nurse (LPN) | Documented missing fentanyl patch in resident's MAR |
| H | Housekeeper | Interviewed regarding missing fentanyl patch |
Inspection Report
Routine
Deficiencies: 1
Date: Mar 19, 2024
Visit Reason
The inspection was conducted to assess compliance with care standards, specifically focusing on the provision and documentation of oral care for residents.
Findings
The provider failed to ensure consistent performance and accurate documentation of oral care for three of four sampled residents, with observations and interviews revealing inadequate oral hygiene assistance and inaccurate record-keeping.
Deficiencies (1)
Failure to ensure oral care was consistently performed and accurately documented for residents 2, 3, and 4.
Report Facts
Residents sampled: 4
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in relation to failure to assist resident 2 with oral care as documented |
| CNA F | Certified Nursing Assistant | Named in relation to documenting oral care for resident 3 without verification |
| CNA E | Certified Nursing Assistant | Named in relation to oral care for resident 4 and disposal of toothbrush |
| B | Director of Nursing | Interviewed regarding oral care expectations |
| C | Registered Nurse | Interviewed regarding oral care expectations |
| A | Administrator | Interviewed regarding absence of oral care policy |
Inspection Report
Routine
Deficiencies: 3
Date: Sep 28, 2023
Visit Reason
The inspection was conducted to assess compliance with regulations regarding the labeling, handling, and storage of drugs and biologicals, specifically focusing on cytotoxic agents used in the facility.
Findings
The provider failed to ensure consistent labeling and appropriate handling instructions for cytotoxic medications for five sampled residents. Several medications labeled as hazardous lacked proper administration instructions and black box warnings, and staff were unaware of the hazards associated with some medications.
Deficiencies (3)
Failure to provide proper administration instructions for finasteride and paroxetine medications labeled as hazardous.
Lack of black box warnings on finasteride medications regarding proper handling, administration, and destruction.
Staff unawareness of hazardous nature of certain medications and lack of safe handling instructions.
Report Facts
Residents affected: 5
Medication dosage: 5
Medication volume: 15
Medication volume: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN D | Registered Nurse | Interviewed regarding medication labeling and black box warnings |
| RN C | Unit Manager | Interviewed regarding hazardous labeling and medication administration policy |
| Consultant licensed pharmacist E | Pharmacist | Interviewed by phone regarding hazardous medication labeling |
Inspection Report
Deficiencies: 2
Date: Jul 20, 2022
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding maintaining a safe, clean, comfortable, and homelike environment for residents, specifically focusing on the condition of bathroom doors.
Findings
The provider failed to ensure that 12 of 28 bathroom doors were maintained in a safe and homelike manner, with multiple scrapes, gouges, and sharp edges that could cause splinters or injuries. The administrator acknowledged the conditions and noted plans for facility refresh including door replacements.
Deficiencies (2)
The interior bottom twelve inches of the bathroom doors in rooms 1, 3, 7, 9, 10, 11, 16, 17, 18, 20, 24, and 25 had multiple scrapes and gouges with sharp edges that could cause splinters, skin tears, or lacerations.
Walls and door scuffs/chips repaired with paint/stain when needed.
Report Facts
Bathroom doors affected: 12
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