Avantara Watertown
AVANTARA WATERTOWN in WATERTOWN, SD — inspection on April 29, 2026.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the provider's 1/6/25 SD DOH FRI revealed that resident 22 informed director of nursing (DON) B that on his bath days, certified nurse aide (CNA) U had undressed him in his room, covered him with a blanket, then transported him to the shower room. Resident 22 stated he was uncomfortable going through the hallway covered with only a blanket and that he preferred to get undressed in the shower room.
According to the FRI, CNA U had been made aware of the concern and was educated to respect the resident's preference. 2.
Interview on 4/21/26 at 2:15 p.m. with resident 22 revealed that CNA U continued to undress him in his room, cover him with a blanket, and transport him to the shower room. He said it made him uncomfortable and that it happens all the time. 3.
Interview on 4/27/26 at 2:16 p.m. with CNA U revealed that she was aware of resident 22's preference to undress in the shower room rather than his room.
She stated that all residents were undressed in the shower room. 4.
Interview on 4/28/26 at 10:30 a.m. with CNA M revealed that residents with limited mobility use a medical device called a mechanical lift to transfer between beds, wheelchairs, toilets, and shower chairs.
She stated that residents typically get undressed in their room, especially if they're a lift [require a lift to transfer them to the shower chair], then they get undressed in their room and we cover them with a blanket to take them to the shower room. 5.
Interview on 4/28/26 at 4:15 p.m. with resident 3 revealed that he had seen resident 22 transported to the shower room with a blanket over his body [which] means he's undressed. Resident 3 stated that CNA U did not ask resident 3 where he preferred to undress for his baths; instead, she just comes in and says, ?It's time for your bath,' and starts getting me undressed. Resident 3 said that CNA U can be a little picky, so he does what she tells him to do. 6.
Interview on 4/28/26 at 4:20 p.m. with resident 37 revealed that he undressed in his room. He stated, [CNA U] just takes me out of the bed and puts me into the chair to transport, then covers me with a white sheet and takes me to the tub room, without asking him his preferences. He stated that he had also seen other residents transported to the shower room covered by a white sheet. 7.
Interview on 4/29/26 at 8:19 a.m. with DON B revealed that the bathing protocol was to follow the resident's preference to undress in their room or the shower room.
She stated that she had educated CNA U that resident 22 preferred to undress in the shower room and said, Sometimes it might be easier to undress the resident in their room, but [the staff] should follow what the resident wants. 8.
Review of resident 22's 10/25/25 care plan revealed that he required partial assistance with upper body dressing and full assistance with lower body dressing.
His care plan did not indicate any bathing preferences other than frequency. 9.
Review of the provider's 11/18/25 Resident Dignity & Privacy Policy revealed that, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity.
The policy indicated that staff were to groom and dress residents according to their preference and to maintain resident privacy when providing care.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
435068 04/29/2026
Avantara Watertown 415 Fourth Ave NE Watertown, SD 57201
- Take immediate steps to assure the protection of the resident(s).
This may involve separation from
- Notify the appropriate/designated organization/authority that an investigation is being initiated
- Conduct a careful and deliberate investigation centering on facts, observations and statements
- Notify law enforcement authorities if indicated (i.e., a crime such as physical or sexual abuse,
- Report the investigation findings to all necessary state and/or local agencies and any other
immediately following intervention for the resident's safety.
from the alleged victim and witnesses.
theft, etc.).
identified persons as required by law.
The Steps in Abuse Prevention included Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting/Response. .IV.
Identification: Have procedures to: Establish a written policy on how to assist staff in identifying abuse, neglect, exploitation, or misappropriation of property including the types of abuse. .V.
Investigation: Have procedures to: Investigate all allegations of abuse, neglect, exploitation, and misappropriation of property.
Identify [the] staff responsible for [the] investigation.
All allegations will be investigated by the Administrator or Designee immediately. .VII.
Reporting/Response.Have procedures to: All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee.
All allegations of abuse will be reported to your state agency immediately (within 2 hours) after the initial allegation is received. A final investigation report will be submitted to your state agency within 5 working days. If the event that results in [an] allegation of abuse also causes the individual to suspect a crime, the facility will also report to the local law enforcement agency.
Report to [the] State Nurse Registry and/or Department of Professional Regulations if the employer has knowledge of any action by the court of law against the licensed employee.
435068 04/29/2026
Avantara Watertown 415 Fourth Ave NE Watertown, SD 57201
Review of the provider's 5/14/25 Care Plans policy revealed: A Baseline Care plan is started by nursing staff on the first day of admission to provide guidance to direct caregivers as soon as possible after admission and completed no later than 48 hours after admission.
Nursing, Dietary, Activities and Social Services staff complete formal assessments, interviews and observation and begin formulating the full care plan as soon after admission as possible (These departments do have areas that need to be completed by the 48-hour deadline).
The areas that must be addressed in the baseline care plan include the minimum healthcare information necessary to properly care for the resident including, but not limited to: a) Initial goals based on admission orders. b) Physician orders. c) Dietary orders. d) Therapy services. e) Social Services. f) PASARR recommendations, if applicable.
435068 04/29/2026
Avantara Watertown 415 Fourth Ave NE Watertown, SD 57201
Review of the provider's revised 5/14/25 Care Plans policy revealed Individual, resident-centered care planning will be initiated upon admission and maintained by the interdisciplinary team through the resident's stay to promote optimal quality of life while in residence. In doing so, the following considerations are made: 1.
Each resident is an individual.
The personal history, habits, likes and dislikes, life patterns and routines, and personality facets must be addressed in addition to medical/diagnosis-based care considerations. 2.
Each resident has the right to be happy, continue their life-patters as able, and feel comfortable in their surroundings. 3.
Care planning is constantly in process; it begins the moment the resident is admitted to the facility and doesn't end until discharge or death. 4.
Each resident is included in the care planning process and encouraged to achieve or maintain their highest practicable physical and mental abilities through the nursing home stay. 5.
The physician's orders (including medications, treatments, labs, and diagnostics) in conjunction with the resident's plan constitute the total 'plan of care'.
Physician orders are referenced in the resident's care plan, but not rewritten into that care plan.
435068 04/29/2026
Avantara Watertown 415 Fourth Ave NE Watertown, SD 57201
Review of the provider's revised 5/14/25 Elopement policy revealed The facility must take steps to keep the resident safe and assess residents to identify those who are risk for elopement.
Facility personnel must investigate all reports of missing residents.
Elopement drills should be conducted monthly.
Review of the provider's 1/31/26 SD DOH FRI revealed on 1/31/26 at approximately 12:00 a.m., resident 59 was found sitting on the floor between her bed and the bathroom. RN QQ conducted a full body assessment. Resident 59 stated she hit the left side of her head and was transferred to the hospital for further evaluation because she was taking a blood t
435068 04/29/2026
Avantara Watertown 415 Fourth Ave NE Watertown, SD 57201
During destruction of controlled substances, the inventory sheet of specific medications will be evaluated for signs of potential diversion, such as borrowing, consistent administration by one nurse, inappropriate documentation, etc.
435068 04/29/2026
Avantara Watertown 415 Fourth Ave NE Watertown, SD 57201
Review of the providers 4/23/25 updated administrator job description revealed, In keeping with our organization's goal of improving the lives of the residents we serve, the Administrator provides overall direction for all activities related to administration personnel, physical structure, information systems, office management and marketing of the entire facility.
The Administrator works closely with all members of the management team and others to ensure their responsibilities are effectively and consistently discharged .
The Administrator will ensure all facility operations are in compliance with federal, state and local regulations.4.
Review of the providers 12/1/19 updated director of nursing job description revealed In keeping with our organization's goal of improving the lives of the Guests we serve, the Director of Nursing plays a critical role in providing superior customer service and nursing services to all Guests in the facility.
The Director of Nursing is responsible for the planning, development and overall operation of the Nursing Department which ensures Guests receive quality care 24 hours a day.Refer to F-F550, F-F552, F-F554, F-F583, F-F585, F-F600, F-F605, F-F609, F-F628, F-F641, F-F644, F-F655, F-F657, F-F658, F-F689, F-F695, F-F700, F-F755, F-F759, F-F760, F-F761, and F-F806.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.