Avantara Norton

F-F550 occurred on 5/27/24 when resident 1's right to refuse a shower was not honored when staff gave her a shower after she verbalized she did not want to take

a shower, and her previously care planned preferences for showering and bathing were not followed. Based

on the provider's implemented corrective actions the deficient practice confirmed during the survey from 6/19/24 to 6/20/24, the non-compliance is considered past non-compliance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 12 435039 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 435039 B. Wing 06/20/2024

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

Avantara Norton 3600 South Norton Avenue Sioux Falls, SD 57105

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 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm 46453

Residents Affected - Few Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to immediately report allegations of abuse experienced by one of one sampled resident (1). Failure to immediately report allegations of abuse delayed the reporting and investigation process, potentially putting residents at risk for further alleged abuse. 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 SD DOH FRI submitted on 5/28/24 at 11:22 a.m. revealed:

*A written grievance form was reviewed by the administrator on 5/28/24.

*Resident 1 reported that certified nurse aide (CNA) E was rough with her on the morning of 5/27/24.

*She reported that CNA E forced her to wake up at 7:10AM and demanded she take a shower because she urinated on herself, and grabbed her by the arms and pushed her down into the chair.

2. Interview on 6/20/24 at 12:29 a.m. with administrator A and DON B regarding the incident between resident 1 and CNA E revealed:

*It was their expectation to have been notified immediately regarding any potential abuse or neglect situations.

*Administrator A was notified of the situation through a grievance form on 5/28/24.

*She immediately suspended the CNA pending the investigation and spoke with resident 1 regarding the incident.

*She spoke with CNA E to obtain her side of the story.

*As part of the investigation, she:

-Interviewed other residents on the rehab unit to learn if there were any other resident concerns.

-Interviewed staff to learn about their involvement.

-Informed the director of therapy of the situation so she could educate therapy staff about what to report, when to report, and who to report to.

-Reeducated staff from all departments about the provider's abuse and neglect policy and expectations for reporting.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 12 435039 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 435039 B. Wing 06/20/2024

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

Avantara Norton 3600 South Norton Avenue Sioux Falls, SD 57105

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 0609 *Her expectation would have been to allow resident 1 to refuse the shower and to come back later or have a different staff member come back later to assist the resident. Level of Harm - Minimal harm or potential for actual harm *Administrator A denied she had received a text from LPN D on 5/27/24 regarding the incident.

Residents Affected - Few *She informed the staffing agency to not allow CNA E to return to the facility.

The provider implemented actions to ensure the deficient practice does not recur was confirmed after: record

review revealed the facility had followed their quality assurance process, provided education to all staff working within the facility regarding abuse, neglect, and reporting, review of those educational materials and staff signature sheets of acknowledgement of that education, and interviews with several staff from various departments including housekeeping, social services, nursing, and therapy revealed staff understood the education provided regarding abuse, neglect, and the reporting process.

Based on the above information, non-compliance at

F-F609 occurred on 5/27/24 when the allegations of abuse were not immediately reported to the administrator or designee, and based on the provider's implemented corrective actions the deficient practice confirmed during the survey from 6/19/24 to 6/20/24, the non-compliance is considered past non-compliance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 12 435039