Mckenzie County Healthcare Systems Long Term Care

In the surveyor’s words

From the most serious findings on record at Mckenzie County Healthcare Systems Long Term Care, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 23, 2023

  Based on record review, review of the facility reported incident investigation, and resident and staff interview, the facility failed to ensure an environment free of hazards for 1 of 1 sampled resident (Resident #3) injured while consuming a hot beverage. Failure to provide assess and provide the appropriate cup for hot beverages may have contributed to Resident #3's injuries This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Finding include: Review of Resident #3's medial record occurred on 08/23/23 and identified the following: - 07/29/2023 16:11 [4:11 p.m.] General Note: Resident was served Tea upon her request. […]

• Actual harm, isolatedF760Jan 28, 2021

  Based on information from the complainant, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure residents remained free from significant medication errors for 1 of 4 closed records reviewed (Resident #37). Failure to administer the correct dosage of a diuretic and collect labs according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Information provided by the complainant indicated residents were hospitalized due to high sodium levels. Review of facility policy titled Dispensing Medications - [NAME] County occurred on 01/28/21. This policy, reviewed July 2019, stated, . […]

• No harm, potential for more than minimal, widespreadF801Jul 19, 2023

  Based on staff interview, the facility failed to ensure 1 of 1 dietary manager (#1) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure staff have the qualifications to carry out the functions of food and nutrition services has the potential to result in foodborne illness to residents, staff, and visitors. Findings include: During an interview on 07/17/23 at 12:00 p.m., the dietary manager (#1) confirmed he has not completed the necessary courses required for the director of food and nutrition services. […]

• No harm, potential for more than minimal, patternF880Jul 24, 2025

  Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 4 of 5 sampled residents (Resident #1, #7, #15, and #28) observed during cares. Failure to practice infection control standards related to hand hygiene and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 07/24/25. This policy, dated June 2023, stated, . The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of the facility policy titled Enhanced Barrier Precautions occurred on 07/24/25. […]

• No harm, potential for more than minimal, patternF623Jun 20, 2024

  Based on record review and staff interview, the facility failed to provide the resident or the resident's representative a written notice of transfer for 5 of 5 sampled residents (Resident #3, #5, #10, #23, and #28) transferred to the hospital. Failure to provide a written copy of the transfer notice does not allow the resident and/or their representative to make an informed decision regarding their rights. Findings include: Review of Resident #3, #5, #10, #23, and #28's medical records occurred on all days of survey and identified the following hospital transfers: * Resident #3: 10/27/23 and 05/07/24. * Resident #5: 08/04/23. * Resident #10: 04/05/24 and 04/26/24. * Resident #23: 05/03/24. * Resident #28: 04/29/24. […]