Avantara Norton

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

the sensor on the front door to release the lock, allowing the visitor and the resident to open the door and exit the facility.*Camera footage for resident 3 was reviewed for 9/12/25 when the resident eloped. They indicated resident 3, who used a wheelchair independently, had left the facility and gone through the front door around 6:31 p.m. that day.*The front door that resident 3 had exited out of had been locked, but the alarm sensor was bypassed with the use of one of the CNAs ' badges. The badge allowed the sensor on

the front door to release the lock, allowing both CNAs and resident 3 to exit the facility.*They had indicated that at the time of the residents' elopements, the elopement binder was at both nurses' desks and at the front desk. The binder has information on which residents are at an elopement risk, with a picture of each resident for staff to reference.

1. 10. Review of the provider's elopement drills that were first initiated on 7/31/25 through 11/27/25 and the

9/16/25 -9/17/25 Staff In-Service Sheets revealed that all staff were educated on the provider's elopement policy, the binders, and the residents who were currently at risk for elopement.

2. 11. Review of the provider's elopement policy that was last revised on 5/14/25 revealed:*Policy-The facility

must take steps to keep the resident safe and assess residents to identify those who are at risk for elopement. Facility personnel must investigate all reports of missing residents. Elopement drills should be conducted monthly. *Procedures-1. Each resident will be evaluated upon admission to ascertain elopement risk. Care plan interventions will be initiated based on results. Elopement evaluations will be completed upon admission, readmission, significant change, and quarterly. Additionally, the evaluation will be completed should a resident have an elopement.-2. It is the responsibility of all personnel to report any resident attempting to leave the premises or suspected of going missing to the charge nurse immediately. A resident who has been evaluated as safe for leave of absence (LOA) should have a physician's order and sign out before leaving the facility.- .4. Upon return of the resident to the facility, the Director of Nursing or charge nurse should:--a. Examine the resident for injuries.--b. Contact the attending physician and report what happened.--c. Contact the resident's representative and inform him/her of the incident.--d. Complete

an incident report in the Risk Management section of PointClickCare (PCC).--e. Make appropriate notations

in the resident's medical record and update the care plan.--f. Complete the Elopement Risk Evaluation UDA.

3. 12. The provider's 7/31/25 implemented actions to ensure the deficient practice does not reoccur was

confirmed on 12/30/25 after record review revealed the facility had followed their quality assurance process, education was provided to all staff regarding resident elopements, all staff were educated on elopements, interviews revealed staff understood the education provided regarding those topics, observations revealed that staff are present at the front entrance when residents are present to ensure safety, and review of the provider's weekly and monthly elopement drills, and follow up elopement risk assessments revealed substantial compliance.

Based on the above information, noncompliance at F-F689 occurred on 7/26/25 and 9/12/25, and the provider's 7/31/25 and 9/12/25 and implemented corrective actions for the deficient practice confirmed on 12/30/25. The noncompliance is considered past noncompliance.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/30/2025

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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

facility on [DATE REDACTED]. His admission hot liquids safety assessment completed that day indicated that he required hot liquid safety measures such as a lidded cup and staff assistance with hot liquids.A hot liquid safety assessment was completed upon his admission to the facility and every three months afterwards. On 3/15/25, he was reassessed as safe and resident is not considered to be at risk related to hot liquids at this time. The lidded cup was removed from the intervention list. On 6/16/25, he was reassessed as needing hot liquid safety interventions of staff assistance and hot beverage at table. On 9/16/25, he was assessed as not a risk at this time, with the interventions remaining the same as 6/16/25. On 12/18/25, he was assessed as not a risk at this time.Resident 4 was reassessed for hot liquid safety on 12/19/25 after his spill of the hot soup, which indicated he was a low risk. A comment was added that read, Resident has a history of hot liquid spill/injury, new intervention is required. The intervention included using a lid on the cup or mug.14.

Review of the provider's 11/18/25 Hot Liquid Safety policy revealed that staff should serve the hot beverages between 140 and 155 degrees. Hot liquid temperatures should be taken and recorded at every meal and/or when prepared to ensure the temperature is within the above parameters before being served.15. The provider's 12/19/25 implemented actions to ensure the deficient practice does not reoccur was confirmed on 12/30/25 after record review revealed the facility had followed their quality assurance process, education was provided to dietary staff regarding acceptable serving temperatures, all staff were educated on hot liquid safety, interviews revealed staff understood the education provided regarding those topics, observations revealed that the dietary staff appropriately adjusted the temperature of the food to ensure safety, and a review of the provider's follow-up monitoring process revealed substantial compliance.Based on the above information, noncompliance at F-F804 occurred on 12/19/25, and the provider's 12/19/25 implemented corrective actions for the deficient practice confirmed on 12/30/25, the noncompliance is considered past noncompliance.

Event ID:

Facility ID:

If continuation sheet