Avantara Watertown

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

41.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 34 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 41.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 48 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.25 therapist hours per resident per day in 2026Q1 — more than 33% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 51 beds and averages 46.6 residents a day — about 91% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.06 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.87 hrs/resident/day on weekends vs 3.85 on weekdays — 26% thinner on weekends — a notable drop. RN hours go from 1.27 to 0.57 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

32 citations, most serious first. The 14 most serious are shown; the remaining 18 are one tap away and print in full.

• Immediate jeopardy · K2026-04-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. He stated they had been like that since he admitted to the facility. 2. Observation on 4/22/26 at 3:27 p.m. of resident 35's bed revealed there was a gap of five inches between the top of his mattress and the headboard. The top opening of his bilateral side rails measured four…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2026-04-29 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. The provider failed to report and investigate the allegation of abuse to other entities, provide education to all staff, interview any further residents and staff regarding the allegation, and provide safety to resident 21 and all the residents to prevent similar situations from occurring. Administrator A was notified…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-04-29 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 resident (3) who was administered the incorrect physician-ordered dose of insulin by licensed practical nurse (LPN) (W) which increased his risk for having diabetic complications, including hypoglycemia (an abnormally low blood…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-03-06 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Review of the provider's 2/21/25 SD DOH FRI regarding resident 1 revealed: *Resident 1 had several changes in the frequency and dosage of furosemide (a diuretic medication that reduces extra body fluid) since her admission in response to weight gain and increased edema (fluid retention) in her extremities. *Upon receiving orders for medication changes, the facility faxed the pharmacy the new…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Past Non-Compliance
• Potential for harm · E2026-06-17 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, observation, record review, and policy review, the provider failed to ensure residents received care in accordance with their plan of care by two of two certified nursing assistants (CNAs) (N and Q) who did not change six of eight sampled residents' (1, 2, 3, 4, 5, and 6) incontinence (involuntary urine or bowel leakage) products during the night shift and did not reposition one of one sampled resident (4) who was found sideways in bed with urine-stained bedsheets, and by one of one contracted travel CNA (Z) who left one of one sampled resident (5) alone in the dining room for over three hours. Findings include: 1. Review of the provider's 6/16/26 at 1:00 p.m. SD DOH FRI revealed CNA M reported to the director of nursing (DON) B and regional nurse consultant (RNC), unidentified in report, that at the start of the day shift (6:30 a.m.), she found several residents who were heavily incontinent. She described resident 1…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · F2026-04-29 · tag F0583 — failed to protect personal privacy — widespread
  Keep residents' personal and medical records private and confidential.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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. with administrator A revealed that the document contained confidential information and was in an area that was accessible to the public. She agreed this was a violation of resident confidentiality. 3. Review of the provider's 11/18/25 Medical Records: Storage & Destruction policy revealed that the resident's record set was comprised of the resident's medical and billing record,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-04-29 · tag F0835 — failed to run the facility competently — widespread
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, policy review, and job description review, the provider failed to ensure the facility was operated and administered by administrator A and director of nursing (DON) B in a manner that ensured quality of life and overall well-being for all 45 residents in the facility.Findings include:1. Observations, interviews, record reviews, and policy reviews throughout the survey on 4/21/26 through 4/23/26 and 4/27/26 through 4/29/26 revealed administrator A and DON B did not ensure the management, safety, quality of life, and overall well-being of all the residents who lived at the facility. Those were evidenced by a widespread system breakdown to ensure services provided met professional standards as it pertained to resident dignity, informed decision for psychotropic medications, resident self-administration of medications, resident meal choices/preferences, responses to resident concerns after resident council meetings, resident health information security, how to file a grievance, allegations of resident abuse, consent/diagnoses for…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-04-29 · tag F0837 — widespread
  Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, record reviews, and policy reviews, the governing body failed to ensure the facility was operated in a manner that ensured the safe management and overall well-being of 45 residents in the facility.Findings include:1. Observations, interviews, record reviews, and policy reviews throughout the survey on 4/21/26 through 4/23/26 and 4/27/26 through 4/29/26 revealed administrator A and DON B did not ensure the management, safety, quality of life, and overall well-being of all the residents who lived at the facility.Those were evidenced by a widespread system breakdown to ensure services provided met professional standards as it pertained to resident dignity, informed decision for psychotropic medications, resident self-administration of medications, resident meal choices/preferences, responses to resident concerns after resident council meetings, resident health information security, how to file a grievance, allegations of resident abuse, consent/diagnoses for psychotropic medications, reporting allegations timely, Ombudsman reports upon discharge,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-04-29 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespread
  Have a plan that describes the process for conducting QAPI and QAA activities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and quality assurance and performance improvement (QAPI) plan policy review, the provider failed to ensure they had identified and corrected quality deficiencies when they occurred throughout the facility and that performance improvement projects (PIP) were thoroughly identified, implemented, or monitored related to quality of care, quality of life, and safety concerns for areas affecting residents such as siderails on residents' beds, incident reporting, medication administration and storage, and baseline care plans.1. Interview on 4/29/26 at 9:30 a.m. with administrator A regarding the QAPI program and committee revealed that she was the QAPI coordinator for the provider and that each department manager conducted their own audits. She reviewed and consolidated the reports to be discussed at the QAPI meeting. The QAPI committee reviewed the reports and implemented any plan needed for correction. The provider's QAPI committee was comprised of all the department managers, administrator A, director of nursing (DON) B, the medical director, pharmacist, consultant…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-04-29 · tag F0550 — failed to protect resident dignity and rights — pattern
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, interview, record review, and policy review, the provider failed to ensure that staff protected three of four sampled resident's (3, 22, 37) right to a sense of dignity, respect, and self-determination regarding bathing preferences. Findings include: 1. 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…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-04-29 · tag F0585 — failed to handle grievances — pattern
  Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, resident council meeting interview, and policy review, the provider failed to:*Ensure prompt response to call light times, and that the necessary cares and services were provided within a timely manner for four of four residents (2,16, 24, and 61) to maintain their physical, mental, and emotional well-being. *Implement an effective grievance process to ensure residents' have the knowledge on how to file a grievance, where the grievance forms are located at and a process in place on how to file grievances anonymously.Findings Include:1. Interview on 4/21/26 at 9:38 a.m. with resident 16 revealed the problems with living in this facility is that she is not getting help when she needs it. She revealed that sometimes she had to wait an hour to have staff come to help her in her room. She used her call light for the staff to help her change positions, or to help with personal cares from being incontinent (involuntary urine or bowel leakage) of urine. She said, I will just be soaking…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-04-29 · tag F0609 — failed to report abuse allegations — pattern
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and policy review, the provider failed to implement procedures to ensure allegations of abuse were reported to the required entities for two separate allegations of abuse:*A sexual abuse allegation made by one of one sampled resident (21) to registered nurse (RN) F and RN D involving certified nursing assistant (CNA) E and an unidentified staff member.*A possible financial abuse allegation made by one of one sampled resident's (40) family member to social services designee (SSD) J.Findings include: 1. Observation on 4/21/26 at 9:17 a.m. of resident 21 in the hallway revealed he reported to RN D that contracted travel CNA E had touched him in a private area without his consent, which upset him (resident 21). RN D told the resident they had handled that situation. 2. Interview on 4/21/26 at 10:02 a.m. with resident 21 revealed that he was touched in a private area without his consent by one of one contracted travel certified nursing assistant (CNA) (E). At 6:00 a.m. on 4/21/26, he woke up with a quick startle when someone had their hands…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-04-29 · tag F0655 — pattern
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the provider failed to ensure the resident's baseline care plan (personalized plan that addresses a resident's care needs, goals, and interventions) included the minimum healthcare information necessary to properly care for the resident, and that the care plan was completed within 48 hours of the resident's admission to the facility for six of 19 sampled residents (2, 4, 7, 33, 40, and 59), and was reviewed with, and a copy was offered to the resident or the resident's representative within 48 hours of the resident's admission to the facility for six of seven newly admitted sampled residents (2, 4, 7, 33, 40, and 59). Findings include:1. Review of resident 4's electronic medical record (EMR) revealed he was admitted to the facility on [DATE]. There was an uploaded signed paper copy of his baseline care plan. It was signed by resident 4's representative on 9/25/25 to indicate that they had received a copy and that it was reviewed with them. His 9/25/25…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-04-29 · tag F0657 — failed to keep the care plan current — pattern
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the provider failed to ensure the care plan (personalized plan that addresses a resident's care needs, goals, and interventions) was reviewed and revised to reflect the current care needs for four of nineteen sampled residents (13, 33, 38, and 40).Findings include:1. Review of resident 40's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Her 4/5/26 Brief Interview of Mental Status (BIMS) assessment score was a 9, which indicated his cognition was moderately impaired. Her diagnoses included Diabetes Mellitus (a condition involving disruptions in how the body regulates blood sugar), Parkinson's Disease (a brain disorder that makes it hard for a person to control their body movements), Alzheimer's Disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), Dementia (a group of symptoms affecting memory, thinking, and social abilities), Major Depressive Disorder,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$6,368 in federal fines across 1 penalty.

• $6,368 — penalty dated 2025-03-06

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to LEGACY HEALTHCARE — 89 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 21 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $766K paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in SD