Avantara Watertown
415 Fourth Ave NE, Watertown, SD 57201 · Codington County · 51 certified beds · avg 47 residents/day · certified since Mar 1, 1993
Abuse citation flag (CMS)SFF Candidate
Part of chain: LEGACY HEALTHCARE (89 facilities, chain avg rating 2.9★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Apr 29, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Jun 2, 2026 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Apr 29, 2026 · F-0600
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jun 2, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 29, 2026 · F-0760
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 2, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 6, 2025 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 28, 2025 (Past Non-Compliance)
All citations in the current public record (32)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 17, 2026 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Apr 29, 2026 | ▲ K · Immediate jeopardy, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 29, 2026 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Apr 29, 2026 | ▲ G · Actual harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Apr 29, 2026 | F · Potential for harm, facility-wide | The facility did not keep residents' personal and medical information private and confidential. |
| Apr 29, 2026 | F · Potential for harm, facility-wide | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint |
| Apr 29, 2026 | F · Potential for harm, facility-wide | The facility did not have a proper governing body legally responsible for its policies and operations, or that body failed to appoint a properly licensed administrator to manage the facility. |
| Apr 29, 2026 | F · Potential for harm, facility-wide | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. |
| Apr 29, 2026 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Apr 29, 2026 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Apr 29, 2026 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Apr 29, 2026 | E · Potential for harm, repeated | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| Apr 29, 2026 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Apr 29, 2026 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Apr 29, 2026 | E · Potential for harm, repeated | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Apr 29, 2026 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Apr 29, 2026 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Apr 29, 2026 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Apr 29, 2026 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Apr 29, 2026 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Apr 29, 2026 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Apr 29, 2026 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Apr 29, 2026 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Apr 29, 2026 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Apr 29, 2026 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 29, 2026 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Mar 6, 2025 | ▲ G · Actual harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Dec 5, 2024 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Dec 5, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Dec 5, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Mar 19, 2024 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Sep 28, 2023 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (3 → 23).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 1 | 0 | E |
| 2024 | 4 | 0 | E |
| 2025 | 1 | 1 | G ▲ |
| 2026 | 26 | 3 | K ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $6,368.
| Date | Type | Amount / length |
|---|---|---|
| Mar 6, 2025 | Fine | $6,368 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | South Dakota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.04 | 4.32 | 3.95 | bottom 6% in South Dakota; bottom 15% in the U.S. |
| Registered Nurse hours | 0.91 | 0.91 | 0.69 | top 45% in South Dakota; top 20% in the U.S. |
| Weekend total nurse staffing | 2.44 | 3.71 | 3.50 | bottom 4% in South Dakota; bottom 8% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.57 | 0.51 | 0.48 | top 32% in South Dakota; top 26% in the U.S. |
| Total nursing staff turnover (%) | 44.2 | 48.2 | 45.8 | top 43% in South Dakota; top 48% in the U.S. |
| RN turnover (%) | 27.3 | 34.7 | 42.9 | top 38% in South Dakota; top 24% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.57, RN 1.06, weekend 2.87. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Doros Generation Trust U/A/D 1/3/12 | Organization | 5% or Greater Direct Ownership Interest | 43% | 07/01/2019 |
| GPN Family Trust U/A/D 4/28/08 | Organization | 5% or Greater Direct Ownership Interest | 43% | 07/01/2019 |
| Oakway Operations LLC | Organization | 5% or Greater Direct Ownership Interest | 15% | 07/01/2019 |
| Doros Generation Trust U/A/D 1/3/12 | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| GPN Family Trust U/A/D 4/28/08 | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| Legacy Healthcare Financial Services LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| Rajchenbach, Chaim | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2019 |
| Rajchenbach, Chaim | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2019 |
| Rajchenbach, Chaim | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| RSM Us LLP | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Shabat, Menachem | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2019 |
| Shabat, Menachem | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2019 |
| Shabat, Menachem | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| Shives, Aaron | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2019 |
| Shives, Aaron | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2019 |
| Speier, Lynna | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2025 |
| Speier, Lynna | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2025 |
| Truist Bank | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 04/01/2022 |
| Truist Bank | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2022 |
| Watertown SD Property Holdings, LLC | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 07/01/2019 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How do you protect residents' privacy, both in their medical records and in day-to-day care?"
- "What were the findings behind this administration citation, and what has leadership changed since?"
- "Who owns and governs this facility, and how long has the current administrator been here?"
- "How does your quality improvement program work, and can you share a recent example of a problem you found and fixed?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Jenkin's Living Center | 0.7 mi | Watertown, SD | ★★★☆☆ | 3/5 |
Compare this facility with the 1 closest →
Facility data as of CMS processing date 2026-08-01. CCN 435068.