The Vardell Report.Avantara Groton

Across 4 inspections from April 2023 to December 2025, state surveyors documented 22 findings at Avantara Groton; 22 have a recorded correction; CMS lists 1 enforcement action in the window.

Inspections

4

2023–2025, standard and complaint

Findings

22

Deficiencies cited by state inspectors

Corrected

22

Of 22 findings, with a recorded correction date

Penalties

1

1 fine; payment not published

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Dec 112025

   Standard health inspection

   9 findings

   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel FNo actual harm, potential for moreCorrected Jan 25, 2026
   • F641Ensure each resident receives an accurate assessment.Level ENo actual harm, potential for moreCorrected Jan 25, 2026
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected Jan 25, 2026
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jan 25, 2026
   • F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level DNo actual harm, potential for moreCorrected Jan 25, 2026
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Jan 25, 2026
   • F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.Level DNo actual harm, potential for moreCorrected Jan 25, 2026
   • F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Level DNo actual harm, potential for moreCorrected Jan 25, 2026
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level DNo actual harm, potential for moreCorrected Jan 25, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Nov 262024

   Complaint investigation

   1 finding

   • F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level GActual harmCorrected Oct 24, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Jul 312024

   Standard health inspection

   3 findings

   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level ENo actual harm, potential for moreCorrected Aug 27, 2024
   • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Aug 27, 2024
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Aug 27, 2024

   Enforcement Action

   Civil money penalty, $6,168 imposed November 26, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of July 31, 2024, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Apr 142023

   Standard health inspection

   9 findings

   • F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level ENo actual harm, potential for moreCorrected May 29, 2023
   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel ENo actual harm, potential for moreCorrected May 29, 2023
   • F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level ENo actual harm, potential for moreCorrected May 29, 2023
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected May 29, 2023
   • F559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.Level DNo actual harm, potential for moreCorrected May 29, 2023
   • F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level DNo actual harm, potential for moreCorrected May 29, 2023
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected May 29, 2023
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected May 29, 2023
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level DNo actual harm, potential for moreCorrected May 29, 2023

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Treatment Choices and Advance Directives, Cited in Two Inspections

   Inspectors cited F578 in November 2024 and December 2025. This citation covers residents’ right to accept or refuse treatment and to make an advance directive. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242425F578 across all 4 inspections, oldest to newest
2. 2

   The First 48 Hours, Cited in Two Inspections

   Inspectors cited F655 in April 2023 and December 2025. This citation covers the baseline care plan for a new resident’s immediate needs, due within 48 hours of admission. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242425F655 across all 4 inspections, oldest to newest
3. 3

   Professional Standards, Cited in Two Inspections

   Inspectors cited F658 in April 2023 and December 2025. This citation covers whether the home’s services meet professional standards of quality. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242425F658 across all 4 inspections, oldest to newest
4. 4

   Medication Labeling and Storage, Cited in Two Inspections

   Inspectors cited F761 in April 2023 and December 2025. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242425F761 across all 4 inspections, oldest to newest
5. 5

   Infection Control, Cited in Two Inspections

   Inspectors cited F880 in July 2024 and December 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242425F880 across all 4 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   How are a resident’s advance directive and treatment wishes recorded and shared with every shift?

   Treatment Choices and Advance Directives: cited in two inspections, most seriously at level G.

2. 02

   What happens in the first 48 hours after admission, and who writes the first care plan?

   The First 48 Hours: cited in two inspections, most seriously at level F.

3. 03

   How do you check that nurses and aides follow professional standards, and what happens when they do not?

   Professional Standards: cited in two inspections, most seriously at level D.

4. 04

   How are medications stored and secured, and who checks the medication carts?

   Medication Labeling and Storage: cited in two inspections, most seriously at level E.

5. 05

   Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

   Infection Control: cited in two inspections, most seriously at level E.

6. 06

   How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

   No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.

7. 07

   What led to the 2024 fine, and has it been paid?

   A $6,168 civil money penalty was imposed November 26, 2024. CMS publishes the fine, not whether it has been paid.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the South Dakota state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  South Dakota state survey agency

  Inspection Apr 14, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  South Dakota state survey agency

  Inspection Jul 31, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  South Dakota state survey agency

  Inspection Nov 26, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  South Dakota state survey agency

  Inspection Dec 11, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 435048

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.