Avantara Watertown, Watertown, South Dakota

32
Citations from health inspectionsSouth Dakota average: 17 a home: 4
Residents harmed or put in dangerSouth Dakota average: 2.5 a home: $71,591
Fines from the federal governmentSouth Dakota average: $40,815 a home: 1 out of 5
Overall rating in starsSouth Dakota average: 2.9

The figures come from Medicare Care Compare files released October 8, 2026 by CMS, the federal Medicare agency. The citations span each home's three most recent inspection cycles plus their complaint visits, going back to March 2017 at the earliest; the fines span about three years, beginning September 2023. Browse the CMS files

Six inspection visits produced 32 citations. Residents were in immediate danger in two findings. Residents were found hurt in two cases. Federal fines came to $71,591 (three fines).

A candidate for Special Focus. For its list of nursing homes with past poor inspection results, CMS has named this home a candidate.

The CMS abuse icon is shown for this home. Care Compare adds it after a citation for abuse or neglect. Either a resident was harmed recently, or harm could have resulted over two inspections in a row.

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Quick Look at the Record

The home's overall star rating: 1 out of 5
Rating for health inspections: 1 out of 5
Rating for staffing: 3 out of 5
Rating for quality of care: 2 out of 5
Nurse time for each resident: 3.57 hours each dayThe South Dakota average is 3.79 hours
Time from registered nurses: 1.06 hours each dayThe South Dakota average is 0.80 hours
Nursing staff who left during one year: 44.2%against the South Dakota average of 48.2%
Beds that are certified: 51
Ownership: Limited Liability company (for profit)
Chain: Legacy Healthcare, with 95 homes
Street address: 415 Fourth Ave Ne, Watertown, South Dakota 57201
County: Codington

Each inspection's citations

Every citation marks a federal rule inspectors found broken, along with its seriousness and the number of residents affected.

One citation dated June 17, 2026

F684 Quality of Care: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.

25 citations dated April 29, 2026

F865 Written Quality Improvement Plan: risk of harm, no one found hurt, widespread.
F837 Governing Body and Licensed Administrator: risk of harm, no one found hurt, widespread.
F835 Run the Facility Effectively: risk of harm, no one found hurt, widespread, found on a complaint visit.
F806 Food That Meets Allergies and Preferences: risk of harm, no one found hurt, one or a few residents.
F761 Labeling and Locking Up Medicines: risk of harm, no one found hurt, one or a few residents.
F760 Significant Medication Errors: residents were harmed, one or a few residents.
F759 Medication Error Rate of 5 Percent or More: risk of harm, no one found hurt, one or a few residents.
F755 Pharmacy Services: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F700 Safe Use of Bed Rails: risk of harm, no one found hurt, a pattern, several residents.
F695 Breathing and Oxygen Care: risk of harm, no one found hurt, a pattern, several residents.
F689 Accident Hazards and Supervision: immediate danger to residents, a pattern, several residents, found on a complaint visit.
F658 Care That Meets Professional Standards: risk of harm, no one found hurt, one or a few residents.
F657 Updating the Care Plan on Time: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
F655 Baseline Care Plan at Admission: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
F644 Coordinate Assessments With Mental Health Screening Program: risk of harm, no one found hurt, one or a few residents.
F641 Accurate Resident Assessments: risk of harm, no one found hurt, one or a few residents.
F628 Required Transfer Paperwork and Notices: risk of harm, no one found hurt, one or a few residents.
F609 Reporting Suspected Abuse: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
F605 Avoid Unnecessary Sedating or Psychiatric Drugs: risk of harm, no one found hurt, one or a few residents.
F600 Freedom From Abuse and Neglect: immediate danger to residents, one or a few residents.
F585 Right to File Complaints Without Retaliation: risk of harm, no one found hurt, a pattern, several residents.
F583 Keep Resident Records Private: risk of harm, no one found hurt, widespread.
F554 Let Residents Take Own Medicines When Appropriate: risk of harm, no one found hurt, one or a few residents.
F552 Keep Residents Informed About Health and Care: risk of harm, no one found hurt, one or a few residents.
F550 Dignity and Resident Rights: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.

One citation dated March 6, 2025

F760 Significant Medication Errors: residents were harmed, one or a few residents, found on a complaint visit.

Three citations dated Dec. 5, 2024

F761 Labeling and Locking Up Medicines: risk of harm, no one found hurt, a pattern, several residents.
F755 Pharmacy Services: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
F550 Dignity and Resident Rights: risk of harm, no one found hurt, a pattern, several residents.

One citation dated March 19, 2024

F677 Help With Daily Living: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.

One citation dated Sept. 28, 2023

F761 Labeling and Locking Up Medicines: risk of harm, no one found hurt, a pattern, several residents.

Payment Denials and Fines

Date	Penalty	Amount
April 29, 2026	Fine	$27,378
April 29, 2026	Fine	$37,845
March 6, 2025	Fine	$6,368

Ownership and Management of the Home

The home is run by Truist Bank (operational or managerial control).
The direct 43% owner is Doros Generation Trust U/A/D 1/3/12.
The direct 43% owner is Gpn Family Trust U/A/D 4/28/08.
The direct 15% owner is Oakway Operations LLC.

The CMS Care Compare files, updated every month, provide provider information, health deficiencies, penalties, and ownership. The CMS certification number is 435068. Other homes in South Dakota.