Avantara Norton

F-F602 occurred on 3/3/25, and based on the provider's implemented corrective action for the deficient practice confirmed on 4/9/25, the non-compliance is considered past non-compliance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 7 435039 Department of Health & Human Services Printed: 08/29/2025 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 04/10/2025

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 0658 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50915 potential for actual harm A. Based on record review, interview, and policy review, the provider failed to follow professional standards Residents Affected - Some by not having ensured two of two sampled residents (1 and 2) had received their PRN (as needed) controlled (medications with risk for abuse and addiction) pain medications as ordered by the physician. Findings include:

1. Review of resident 1's electronic medical record (EMR) revealed his medication administration record (MAR) indicated:

*He had a physician's order for oxycodone (a controlled pain medication), 5 milligram (mg) tablet, Give 2 tablet[s] orally every 4 hours as needed for pain.

*On 2/17/25, he was given two oxycodone tablets by registered nurse (RN) E at 1:16 a.m., and two oxycodone tablets by licensed practical nurse (LPN) G at 2:12 a.m.

-Less than one hour had passed between those administrations.

*On 3/20/25, he was given one oxycodone tablet by certified medication aide (CMA) F at 4:37 p.m., and two oxycodone tablets by LPN H at 7:35 p.m.

-Less than three hours had passed between those administrations.

On 3/21/25, he was given two oxycodone tablets by LPN I at 5:26 p.m., and two oxycodone tablets by RN J by 7:23 p.m.

-Less than two hours had passed between those administration.

*All of those documented administrations were given before four hours had passed between administrations as ordered.

2. Review of resident 2's EMR revealed her January 2025 MAR indicated:

*She had a physician's order for oxycodone, 5 milligram (mg) tablet. Give 7.5 mg by mouth every 4 hours as needed for pain.

*On 1/3/25 at 1:28 a.m., RN E documented administering resident 2's PRN oxycodone.

-On 1/3/25 at 1:30 a.m., RN E documented administering her an additional dose of oxycodone.

*On 1/21/25 at 2:01 a.m., RN E documented administering resident 2's PRN oxycodone.

*On 1/21/25 at 5:00 a.m., RN E documented administering her an additional dose of oxycodone.

*All of those documented administrations were given before four hours had passed between administrations as ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 7 435039 Department of Health & Human Services Printed: 08/29/2025 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 04/10/2025

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 0658 3. Interview on 4/9/25 at 2:00 p.m. with director of nursing (DON) B revealed:

Level of Harm - Minimal harm or *It was his expectation that medications would be administered following the physician's orders. potential for actual harm *He was not sure if there was a policy that would state if and how early a PRN medication could be Residents Affected - Some administered.

*He thought that if a PRN medication was requested early, it should not have been administered more than 30 minutes before the next ordered dose.

4. Review of the provider's October 2024 medication administration-general guidelines policy revealed:

*Medications were to be administered observing SIX RIGHTS- Right resident, right drug, right dose, right route, right time, and right documentation, are applied for each medication being administered.

*Prior to administration of any medication, the medication and dosage schedule on the resident's medication administration record (MAR) are compared with the medication label.

* Medications are administered in accordance with written orders of the prescriber.

B. Based on record review, interview, and policy review, the provider failed to follow professional standards by not having ensured one of one sampled resident (3) with a documented weight gain had been re-weighed and that the physician was notified of the resident's weight gain according to their policy. Findings include:

1. Review of resident 3's electronic medical record (EMR) revealed:

*She was admitted on [DATE REDACTED] with a diagnoses of:

-congested heart failure (a condition when the heart is unable to pump blood efficiently and causes fluid buildup), and a left hip replacement.

*On 4/4/25, resident 3 had an admission weight of 215 pounds (lbs).

*On 4/5/25, her documented weight was 221 lbs an increase of six pounds.

-There was no documentation of the resident being re-weighed related to the six-pound weight gain.

*On 4/6/25 her documented weight was 227 lbs an increase of six pounds from the previous day's weight.

*There was no documentation of the charge nurse having acknowledged resident 3's weight gain.

*There was no documentation that the physician had been notified of resident 3's twelve-pound weight gain

in two days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 7 435039 Department of Health & Human Services Printed: 08/29/2025 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 04/10/2025

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 0658 Interview on 4/10/25 at 1:55 p.m. with administrator A, director of nursing (DON) B, and regional nurse consultant (RNC) C regarding resident 3' s weights revealed: Level of Harm - Minimal harm or potential for actual harm *RNC C stated that resident 3's weight upon admission of 215 lbs had been her hospital weight and was not obtained upon her admission to the facility. Residents Affected - Some *They agreed that there was no documentation that the physician had been notified of resident 3's weight gain and their policy had not been followed.

Review of the provider's February 2024 Weighing the Resident revealed:

*Report significant weight loss/weight gain to the charge nurse who will report to the registered dietitian and physician.

*If weight does not appear correct, re-weigh resident to ensure weight is accurate. Consider re-weighing the resident if there is a 5-pound difference from the resident's last weight.

45383

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 7 435039