Avantara Norton

F-F880.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 60 435039 Department of Health & Human Services Printed: 09/07/2025 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 03/05/2025

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45383 potential for actual harm Based on observation, interview, and policy review, the provider failed to ensure proper infection control Residents Affected - Some practices had been followed for:

*Two of two sampled residents (5 and 70) who had wound dressings changed by two of two observed staff licensed practical nurse/wound nurse (LPN) M and certified nurse practitioner (CNP) CC.

*Four of four sampled residents (29,34, 345, and 350) who required Enhanced Barrier Precautions (EBP) (an infection control strategy in nursing homes that expands the use of personal protective equipment (PPE) specifically gowns and gloves, during high contact resident care activities to reduce the transmission of multi-drug-resistant organisms (MDROs).

*Four of four sampled residents (5, 6, 35, 37, and 64) who had unlabeled personal care products to identify

the correct resident for usages.

Findings include:

1. Observation on [DATE REDACTED] at 9:13 a.m. with LPN/wound nurse M and CNP CC while they performed a dressing change for resident 70's abdominal wound revealed:

*Dressing supplies had been placed on a clean barrier on the resident's bedside table by LPN/wound nurse M.

*CNP CC had put on a pair of gloves prior to entering the room and then performed wound debridement (removal of dead or infected tissue) to resident 70's abdomen with a gauze pad and then cleaned the wound with Vashe wound wash.

*CNP CC removed his gloves and did not perform hand hygiene (washing or sanitizing of hands) and put on

a new pair of gloves.

*LPN/wound nurse M put on a pair of gloves touched the resident's blanket with her left gloved hand, and used a gauze pad to wipe the wound with her right hand.

*With those same gloved hands, she:

-Opened a sterile tongue depressor and applied collagen powder (to help with wound healing) onto the resident's abdominal wound.

-Used an ink pen from the resident's room, dated the dressing, and applied it to the resident's abdominal wound.

*LPN/wound nurse M removed her gown and gloves, placed them in the garbage, and performed hand hygiene. Then she:

-Left the Vashe wound wash in the resident's room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 60 435039 Department of Health & Human Services Printed: 09/07/2025 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 03/05/2025

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 0880 -Removed the garbage.

Level of Harm - Minimal harm or *Performed hand hygiene before leaving the resident's room. potential for actual harm

Interview with LPN/wound nurse M following the above observation revealed: Residents Affected - Some *She would typically help with cueing wound care personnel about hand hygiene if they did not do that correctly.

*She agreed CNP CC had missed some opportunities when he should have performed hand hygiene.

2. Observation on [DATE REDACTED] at 9:40 a.m. of LPN/wound nurse M and CNP CC while they performed a dressing change on resident 5's right leg wounds revealed:

*CNP CC performed hand hygiene and put on a pair of gloves.

*LPN/wound nurse M had been gathering supplies for the dressing change.

*CNP CC had removed his gloves in the resident's room, performed hand hygiene, and

put on a new pair of gloves.

*With those gloved hands he removed the resident's soiled dressing from the right leg wound.

*He then removed those gloves and put on a new pair of gloves without performing hand hygiene.

*CNP CC then:

-Measured the resident's wound and took a picture of it.

-Touched the camera and screen of the iPad.

-Reached into his pocket of his jacket and grabbed a packaged scalpel and opened the package.

-Removed his gloves and performed hand hygiene.

*LPN/wound nurse M reminded him that they needed to wear a gown while performing the dressing change.

-Resident 5 was on EBP due to his open wound to his right leg.

*CNP CC then applied his gown and with those same pair of gloves he performed wound cleansing to the resident's right leg wound.

*With those same pair of gloves he proceeded to the next task of wound care. He then:

-Began debriding the resident's right leg wound.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 60 435039 Department of Health & Human Services Printed: 09/07/2025 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 03/05/2025

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 0880 -Obtained another picture of the resident's wound.

Level of Harm - Minimal harm or -Touched the iPad screen with his gloved hands. potential for actual harm *Removed his gloves and performed hand hygiene. Residents Affected - Some 3. Observation on [DATE REDACTED] at 6:00 a.m. of resident 34's door revealed there had been one sign on the door requesting for staff/visitors to please knock on the door and wait for him to respond before entering.

Continued observation on [DATE REDACTED] at 6:47 a.m. of resident 34's door now revealed another sign had been added to his door that directed the staff to use EBP when assisting him with personal cares.

Observation and interview on [DATE REDACTED] at 8:49 a.m. with resident 34 while he was lying in bed revealed:

*He had a dressing on his right leg that had been dated [DATE REDACTED].

*He stated he had a skin infection to his right leg and required a dressing change to it every week.

Review of resident 34's electronic medical record (EMR) revealed on [DATE REDACTED] a physician's order had been given for wound care to his right lower leg abrasions.

The EBP sign had not been placed on his door to direct the staff to use the appropriate PPE while assisting him with personal care and wound care until 114 days after it was identified that he had wounds on his right leg that required treatment. The initiation of that sign had not occurred until after the surveyors had entered

the facility and started the survey process.

51472

4. Observation and interview on [DATE REDACTED] at 9:04 a.m. with resident 64 in his room revealed:

*Resident 64 shared a room with resident 35.

*On the counter surrounding the sink were:

-Three syringes and two graduate containers (plastic containers with markings to measure liquid).

--One of those containers was labeled as resident 64's and was dated [DATE REDACTED].

--There were no resident identifiers or dates on the syringes.

-An opened bottle of wound cleanser without a resident's name or date on it.

-Two plastic kidney-shaped basins with a toothbrush and toothpaste in each.

--There were no resident identifiers or dates on those basins or toothbrushes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 60 435039 Department of Health & Human Services Printed: 09/07/2025 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 03/05/2025

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 0880 -Roll on deodorant without a resident identifier or date when it was opened.

Level of Harm - Minimal harm or -A bladed razor on the shelf above the sink without a resident identifier written on it. potential for actual harm *Under the sink, lying on the floor there was a bedpan that was not in a bag and did not have a resident Residents Affected - Some identifier on it or a date.

*Resident 64 was able to identify the wound cleanser as something that was used to clean around his feeding tube before he had it removed.

*He was unable to identify if any of the other personal supplies were his or his roommates.

5. Interview on [DATE REDACTED] at 1:41 p.m. with CNA U regarding residents' personal supplies revealed:

*They were changed every 14 days or if they were soiled or missing.

*They were to be labeled with the resident's name, room number, and the date of the change.

*The personal items for the resident in bed A were placed on one side of the sink and the personal items for

the resident in bed B were placed on the other side.

*The date on the items were to alert staff when the personal items needed to be changed.

*There was no place to document that the personal items were changed.

6. Interview on [DATE REDACTED] at 2:03 p.m. with assistant director of nursing (ADON) C revealed:

*She was the infection preventionist for the facility.

*Residents' personal supplies were to be changed when worn, soiled, after illness, if expired, or if a change was requested.

*The residents' personal supplies were to be dated and marked with the initials of the resident to determine who the personal supply belonged to.

*She felt the provider needed a better process in place for the replacement of personal supplies.

*It was her expectation that nothing be stored under a sink to protect from contamination and a bedpan that was not in a bag should not have been directly on the floor.

51816

7. Observation on [DATE REDACTED] at 5:59 a.m. of resident 29's room revealed:

*His light was off, and his door was mostly closed.

*There was no personal protective equipment (PPE) (equipment worn to minimize exposure to hazards) or sign posted that indicated staff were to use EBP when providing contact care on his door.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 60 435039 Department of Health & Human Services Printed: 09/07/2025 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 03/05/2025

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 0880 Observation on [DATE REDACTED] at 9:38 a.m. revealed that PPE and a sign that indicated the need for EBP had been placed on his door. Level of Harm - Minimal harm or potential for actual harm Review of resident 29's electronic medical record (EMR) revealed:

Residents Affected - Some *He was admitted on [DATE REDACTED].

*He had a [DATE REDACTED] Brief Interview for Mental Status (BIMS) assessment score of 0, which indicated he had severe cognitive impairment.

*His diagnoses included unspecified dementia, unspecified severity, and presence of other vascular implants and grafts (artificial devices implanted to maintain blood flow).

*A [DATE REDACTED] skin evaluation indicated an open area inside right buttocks and manager on duty notified.

-The presence of a wound would indicate the need for EBP.

*His care plan included a [DATE REDACTED] initiated focus area of EBP for wound care. The EBP sign had not been placed on his door to direct the staff to use the appropriate PPE while performing wound care until 4 days

after it was identified that he had a wound that required treatment. The initiation of that sign had not occurred until after the surveyors had entered the facility and started the survey process.

8. Observation on [DATE REDACTED] at 6:01 a.m. of resident 345 in his room from the hallway revealed:

*He was resting in his bed.

*There was no PPE or any sign indicating the need for EBP on his door.

*He had a urinary catheter (a thin, flexible tube inserted into the bladder to drain urine) hanging on his bed frame.

-The presence of a urinary catheter would indicate the need for EBP.

Interview on [DATE REDACTED] at 6:04 a.m. with certified nursing assistant (CNA) Q when she exited resident 345's room about what care she had provided for him revealed:

*She stated she had just emptied his urinary catheter.

*She had not worn a gown while emptying the urinary catheter.

Interview on [DATE REDACTED] at 6:45 a.m. with resident 345 about his catheter revealed he had been admitted from

the hospital on [DATE REDACTED] with a catheter in place because of an enlarged prostate and difficulty with urination.

Review of resident 345's medical record revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 60 435039 Department of Health & Human Services Printed: 09/07/2025 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 03/05/2025

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 0880 *He was admitted on [DATE REDACTED].

Level of Harm - Minimal harm or *He had a [DATE REDACTED] BIMS assessment score of 15, which indicated he was cognitively intact. potential for actual harm *He did not have a diagnosis that indicated the need for a urinary catheter. Residents Affected - Some *His care plan included a [DATE REDACTED] initiated focus area of EBP for catheter care. The EBP sign had not been placed on his door to direct the staff to use the appropriate PPE while performing catheter care until 5 days

after he was admitted with a catheter. The initiation of that sign had not occurred until after the surveyors had entered the facility and started the survey process.

9. Observation and interview on [DATE REDACTED] at 8:14 a.m. with resident 350 in her room revealed:

*There was PPE and a sign that indicated the need for EBP on the door.

*She said the EBP had just started yesterday on [DATE REDACTED].

*She said staff told her they had to wear a gown now because of her urinary catheter.

*She said she was admitted from the hospital with a catheter in place because of difficulty urinating after surgery.

-The presence of a urinary catheter put her at increased risk for infection and would indicate the need for EBP. The EBP sign had not been placed on her door to direct the staff to use the appropriate PPE while performing catheter care until 7 days after she was admitted with a catheter. The initiation of that sign had not occurred until after the surveyors had entered the facility and started the survey process.

Review of resident 350's medical record revealed:

*She was admitted on [DATE REDACTED].

*She had a [DATE REDACTED] BIMS assessment score of 14, which indicated she was cognitively intact.

*Her orders included:

-A [DATE REDACTED] order to perform catheter cares every shift.

-A [DATE REDACTED] order for EBP for catheter cares.

10. Interview on [DATE REDACTED] at 11:56 a.m. with director of nursing (DON) B revealed:

*All managers can make rounds and participate in EBP initiation for residents that should be on those precautions.

*All nursing staff can initiate EBP for residents.

*He would expect that staff knew how to initiate EBP.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 60 435039 Department of Health & Human Services Printed: 09/07/2025 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 03/05/2025

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 0880 52098

Level of Harm - Minimal harm or 11. Observation on [DATE REDACTED] from 5:55 a.m. through 6:28 a.m. in the East-wing and T-wing units/halls potential for actual harm revealed:

Residents Affected - Some *A musty urine odor was noted down the hallways.

*Resident 37's room revealed:

-A black case storing a wound vac was on the floor at the foot of the resident's bed.

-There was a soiled, unlabeled, empty urinal on his bedside table next to his blue insulated water cup.

-Two soiled, unlabeled urinals were stored on another bedside table next to a Kleenex box and a lift sling.

12. Observation on [DATE REDACTED] at 12:34 p.m. of resident 5 in his room revealed:

*The resident was asleep in bed.

*Two 32-ounce urinals were full of yellow urine and stored over the resident's headboard of the bed.

-The urinals were not dated or initialed.

Observation on [DATE REDACTED] at 1:09 p.m. of resident 5 revealed:

*Resident was awake and in a therapy session.

*There were now, three 32-ounce urinals full of yellow urine stored over the resident's headboard of bed.

-The room smelled of musty urine.

Observation and interview on [DATE REDACTED] at 3:12 p.m. with resident 5 revealed:

*Resident was sitting at edge of his bed and had finished his lunch.

*The three full urinals were still stored and had not been emptied.

-His room had a stronger musty urine smell.

Review of resident 5's EMR revealed:

*He was admitted on [DATE REDACTED].

*His BIMS assessment score completed on [DATE REDACTED] was 15, which indicated he was cognitively intact.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 60 435039 Department of Health & Human Services Printed: 09/07/2025 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 03/05/2025

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 0880 *His diagnoses included acquired absence of left leg above knee and acute kidney failure.

Level of Harm - Minimal harm or *He had a history of urinary incontinence. potential for actual harm *Staff were to provide set-up assistance and assist him as needed with toileting. Residents Affected - Some

Interview on [DATE REDACTED] at 11:14 a.m. with registered nurse (RN) G regarding urinals in resident rooms revealed:

*She stated staff were to check and empty urinals once a shift or as needed.

*Urinals should have been replaced weekly.

*It was her expectation that full urinals should be emptied timely to ensure they were not spilled.

*The other personal care items (toothbrush, denture cup, etc.) should have been replaced monthly or as needed.

Interview on [DATE REDACTED] at 11:22 a.m. with resident 5 revealed:

*He stated the staff did not empty or rinse his urinals unless he put the call light on and asked them to.

*He stated the urinals did not get changed out on a routine basis.

*He stated he would have to tell the staff to rinse them once they emptied them or that would not get completed.

*He stated he would empty and rinse the urinals when staff would not.

13. Observation on [DATE REDACTED] at 11:55 a.m. with resident 6 in his room revealed:

*The bathroom was shared by him and his roommate.

-There was a dirty empty urinal stored on the back of the toilet identified as 300A and dated [DATE REDACTED].

-There was a plastic graduate container stored on the back of the toilet dated ,d+[DATE REDACTED] with no other identifiers.

*There was a red basket stored on the counter left of the sink with no resident identifier that contained:

-A 500ml bottle of equate mouth wash with no resident identifier.

-A bottle of men's aftershave with no resident identifier.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 60 435039 Department of Health & Human Services Printed: 09/07/2025 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 03/05/2025

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 0880 -A spray bottle of clean and free peri cleanser with no resident identifier.

Level of Harm - Minimal harm or -A white toothbrush with no resident identifier. potential for actual harm -Three used 60cc plastic irrigation syringes were stored in opened packages. One was dated [DATE REDACTED] and not Residents Affected - Some initialed, one was dated [DATE REDACTED] and initialed, and one was dated [DATE REDACTED] and initialed.

*The left counter stored an incentive spirometer (a handheld medical device used to help improve lung function) with no resident identifier.

*A graduated plastic container identified as resident 6 and dated [DATE REDACTED].

-It stored an unpackaged 60cc irrigation syringe with no date and initials.

*A pair of scissors with no resident identifier.

*A hairbrush with no resident identifier.

*There was a small clear plastic bin stored on the counter to the right of the sink with no resident identifier that contained:

-An opened catheter insertion tray that expired on [DATE REDACTED].

-A paper bag labeled Crest that contained gauze and flossing picks with no resident identifier.

-A tube of toothpaste with no resident identifier.

-A clear plastic cup with no resident identifier.

-A used and undated 30cc plastic syringe that contained 17cc's of unused sterile water with a printed label that read:

-Contents: Sterile Water, To Inflate Catheter Only.

*The right counter stored a container of floss with no resident identifier.

*A small, opened bottle of mouthwash with no resident identifier.

*A [NAME] Norelco electric razor with no resident identifier.

*Stored on the floor under the sink was a gray plastic bedpan dated [DATE REDACTED] with resident 12's initials.

-It was stored on top of a pink plastic basin and was not covered or contained.

-There was no barrier between the pink plastic basin and the bed pan.

*The pink plastic basin was stored on top of a cardboard box.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 60 435039 Department of Health & Human Services Printed: 09/07/2025 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 03/05/2025

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 0880 *A dirty blue disposable glove was on the floor by the cardboard box.

Level of Harm - Minimal harm or *A clear plastic tote with dressing supplies was stored next to the cardboard box. potential for actual harm -The lid for the tote was under the sink against the wall and open to potential contamination. Residents Affected - Some *The trash can had no liner and contained soiled trash.

Review of resident 6's EMR revealed:

*He was admitted to the facility on [DATE REDACTED].

*He had a BIMS assessment score completed on [DATE REDACTED] of 15, which indicated he was cognitively intact.

*Catheter care was to be completed every shift.

*His catheter bag and graduate were to be changed weekly every Sunday night and labeled with his initials and dated.

Interview and observation on [DATE REDACTED] at 10:09 a.m. with resident 6 revealed:

*His catheter drain bag had over 2000 cc of clear, yellow urine in it and was bulging.

*He stated the catheter drain bag had not been emptied for a while.

*The catheter drain bag had a cover but was not dated.

*The spigot was not contained in the holder and was resting on the floor.

14. Observation and interview on [DATE REDACTED] at 8:41 a.m. with resident 12 in his room revealed:

*He used his urinals at bedside independently.

*Two dirty urinals were stored on the edge of his trash can next to his bed.

-One urinal was dated [DATE REDACTED] and initialed.

-The other was labeled with his name, dated [DATE REDACTED] and initialed.

Review of resident 12's EMR revealed:

*He was admitted to the facility on [DATE REDACTED].

*He had a BIMS assessment score on [DATE REDACTED] of 15, which indicated he was cognitively intact.

15. Observation on [DATE REDACTED] at 6:16 a.m. outside of resident 22's room revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 60 435039 Department of Health & Human Services Printed: 09/07/2025 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 03/05/2025

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 0880 *A Droplet infection control precaution sign was posted on the door of the resident's door.

Level of Harm - Minimal harm or *A personal protective equipment (PPE) supply cart with gowns, gloves, eyeglasses/shields, and N95 masks potential for actual harm was set up outside the resident's door.

Residents Affected - Some Interview on [DATE REDACTED] at 6:22 a.m. with LPN M revealed resident 22 had tested positive for COVID.

Review of the [DATE REDACTED] CDC guidelines and recommendations at www.cdc.gov revealed residents should be placed on airborne isolation for SARS COVID pathogen.

Interview on [DATE REDACTED] at 1:56 p.m. with assistant director of nursing (ADON)/infection preventionist C revealed resident 22 would come off the infection control COVID precautions in 10 or 14 days.

Interview on [DATE REDACTED] at 3:21 p.m. with registered nurse (RN) G regarding resident 22 revealed:

*The resident had tested positive with COVID on [DATE REDACTED].

*Staff should have been using droplet precautions with resident.

Review of resident 22's EMR revealed:

*She was on isolation with droplet precautions since [DATE REDACTED].

*She would come off droplet precautions by ,d+[DATE REDACTED].25.

*Her diagnoses included chronic obstructive pulmonary disease, and chronic respiratory failure with hypoxia

*Staff were to use appropriate personal protective equipment and follow droplet precautions.

*Oxygen was to be continuous at 2 lpm via the nasal cannula tubing.

*Nebulizer medications were to be given as ordered for shortness of breath.

Observation on [DATE REDACTED] at 9:34 a.m. outside of resident 22's room revealed:

*The personal protective equipment (PPE) supply cart was removed.

*The Droplet precaution sign had been removed from the resident's door.

*The resident's had come off Droplet precautions on Friday [DATE REDACTED].

16. Interview on [DATE REDACTED] at 9:59 a.m. with CNA T revealed:

*When asked what process was in place for staff to determine who or when a resident should be placed on enhanced barrier precautions (EBP) or transmission-based precautions (TBP).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 60 435039 Department of Health & Human Services Printed: 09/07/2025 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 03/05/2025

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 0880 *She stated if a resident would be admitted with a foley catheter, a nurse would place the proper signage and set up the cart outside of the room. Level of Harm - Minimal harm or potential for actual harm -She stated staff would get a report on the resident at change of shifts.

Residents Affected - Some -She could have located the resident care plan on the kiosk or computer and looked at the resident's information to know how to care for them.

17. Interview on [DATE REDACTED] at 12:08 p.m. with ADON C revealed:

*She was the infection preventionist for the facility.

*She stated catheter care was provided every shift and as needed.

-The certified nursing assistants and nurses could complete the catheter care tasks.

*Catheter supplies should have been stored in the central supply room, the medication carts, or the medication storage room.

*Catheter supplies should not have been stored in resident rooms.

*It was her expectation that full urinals should have been emptied timely.

18. Review of the provider's [DATE REDACTED] Care and Storage of Personal Care Items revealed:

*Personal care items such as razors, combs, denture cups, shall be labeled, if applicable, with the resident's name and stored separately from that of their roommate.

*If a personal care item is found to be left out in a shared space, it will be discarded and replaced with a new one, or if cleanable, will be disinfected prior to return to appropriate storage area.

Review of the provider's [DATE REDACTED] Enhanced Barrier Precautions policy revealed:

*Enhanced Barrier Precautions (EBP) should be used for all residents with wounds or indwelling devices.

*They are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.

Review of the provider's [DATE REDACTED] Transmission Based Precautions policy revealed:

*The facility will not use Airborne Precautions due to no availability of Airborne infection isolation room (air/negative pressure room).

*Our facility does not have Airborne Infection Isolation (AIIR) rooms and thus cannot provide Airborne isolation in our facilities.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 60 435039 Department of Health & Human Services Printed: 09/07/2025 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 03/05/2025

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 0880 *Any resident suspected of having an Airborne infectious disease shall be masked and transported to a facility with an AIIR room. Level of Harm - Minimal harm or potential for actual harm *This includes measles, varicella, and tuberculosis.

Residents Affected - Some *For diseases with multiple routes of transmission, more than one transmission-based precaution category may be required (e.g. Droplet and Contact for COVID-19).

*Contact precautions or Droplet precautions, whether used singly or in combination, must always be used in addition to Standard precautions.

*Under certain circumstances, such as a novel respiratory infection (e.g., COVID-19) the CDC recommends

the use of both Contact precautions and Droplet precautions together.

Review of the provider's [DATE REDACTED] Hand Hygiene policy revealed:

*This facility considers hand hygiene the primary means to prevent the spread of infection. Hand Hygiene is part of Standard Precautions.

*In most situations, the preferred method of hand hygiene is with an alcohol-based had rub. If hands are not visibly soiled, use an ABHR containing ,d+[DATE REDACTED]% ethanol or isopropanol or 65% alcohol if had wipes utilized, for all the following situations:

-When entering and leaving a Resident care area/room.

-Before donning and after removing gloves.

-After handling used dressings, contaminated equipment, etc.

*The use of gloves does not replace handwashing/hand hygiene. Hand hygiene must be completed prior to and after removal of gloves.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 60 435039