Ave Maria Village

F-F600 is considered past non-compliance. The facility implemented corrective actions for the residents affected by the deficient practice and put measures in place to ensure the deficient practice does not reoccur by:

* Immediately contacting the CNA (#5) accused of abuse to discuss the concerns reported by staff,

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 3 355082 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 355082 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Smp Health - Ave Maria 501 19th St NE Jamestown, ND 58401

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 * Placing the CNA (#5) on suspension until further notice, pending the results of the investigation,

Level of Harm - Actual harm * Interviewing all of the staff members (#1, #2, #3, and #4) that reported concerns,

Residents Affected - Few * Reporting the concerns to the North Dakota Department of Health and Human Services,

* Reporting the concerns to local Police Department,

* Re-educating all staff members of the facility's reporting expectations on 06/07/24,

* Re-educating all staff members of the facility's Abuse Policy starting on 06/11/24,

* Completing audits pertaining to abuse/neglect.

This surveyor determined a deficient practice existed on 06/07/24. The facility implemented corrective action and all staff education by 06/11/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 3 355082