Every finding on record at Mountrail Bethel Home

Based on review of the facility assessment, review of the new employee checklist, review of the certified nurse aide (CNA) orientation packet, and staff interview, the facility failed to provide the required CNA training for dementia management. Failure to provide dementia management training limits the CNA's ability to effectively care for residents with dementia and promote the residents' highest level of functioning. Findings include:Review of the most recent facility assessment occurred on all days of the survey and stated, . the facility is licensed for 36 LTC [long term care] beds with 15 of those residents diagnosed with cognition issues . Dementia . Review of the facility checklist for new employees and the CNA orientation packet lacked evidence of dementia management training. During an interview on 03/04/26 at 11:12 a.m., an administrative staff nurse (#1) confirmed the facility's new hire/CNA orientation failed to include dementia management training and the facility failed to provide this required training to all current staff for over a year.

Based on review of the facility assessment, review of the facility training/education documents, and staff interview the facility failed to provide the required behavioral health training to include care specific to the individual needs of residents diagnosed with dementia. Failure to provide behavioral health training limits the staffs' ability to effectively care for residents with behaviors and promote the residents' highest practicable level of functioning.Findings include:Review of the most recent facility assessment occurred on all days of the survey and stated, . the facility is licensed for 36 LTC [long term care] beds with 15 of those residents diagnosed with cognition issues . Dementia . Review of the facility training documents occurred on 03/04/26 and included:* Nursing orientation checklist* New employee checklist* CNA orientation packet* Employee Handbook revised 06/27/24The above documents lacked evidence of dementia management or behavioral health care training.During an interview on 03/04/26 at 11:12 a.m., an administrative staff nurse (#1) confirmed the facility failed to provide dementia management training or behavioral health care training for new and current facility staff members.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 17 sampled residents (Resident #1). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents.Finding include:The Long-Term Care Facility RAI User's Manual, revised October 2025, pages A-30-32, stated, . Section A1500: Preadmission Screening and Resident Review (PASRR) . Coding Instructions . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness . and continue to A1510 . Section A1510 . Coding instructions Code A, Serious mental illness: if resident has been diagnosed with a serious mental illness .Review of Resident #1's medical record occurred on all days of survey. A PASRR Level II, dated 05/16/23, identified diagnoses of bipolar disorder and anxiety disorder. A comprehensive MDS, dated [DATE], showed the facility failed to code Sections A1500 and A1510 for serious mental illness.During an interview on 03/05/26 at 9:35 a.m., an administrative staff member (#5) confirmed the facility failed to code sections A1500 and A1510 accurately.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 5 sampled residents (Resident #24 and #32) observed during cares. Failure to practice infection control standards related to hand hygiene has the potential to spread infection throughout the facility. Findings include:Review of the facility policy titled Hand Hygiene Policy at Mountrail Bethel Home occurred on 03/05/26. This policy, dated December 2020, stated, . All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 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. - Observation on 03/02/26 at 4:15 p.m. showed two certified nurse aides (CNAs) (#2 and #3) entered Resident #24's room to complete perineal cares. Without performing hand hygiene, both CNAs applied gloves, removed the resident's pants, and one CNA (#3) removed the wet brief and provided perineal care. With the same gloves, the CNA (#3) picked up the resident's shoes, and the other CNA (#2) cued the CNA (#3) to change gloves. The CNA (#3) dropped the shoes, removed her gloves, and without performing hand hygiene, applied clean gloves, and placed the shoes on the resident's feet and both CNAs transferred the resident into the wheelchair. The CNA (#3) failed to perform hand hygiene before applying clean gloves.- Observation on 03/02/26 at 4:56 p.m. showed two CNAs (#6 and #7) entered Resident #32's room to complete perineal cares. Both CNAs performed hand hygiene, applied gloves, removed the resident's wet brief and provided perineal cares. Without removing their gloves, both CNAs applied a clean brief. One CNA (#7) removed her soiled gloves, completed hand hygiene, and applied clean gloves. The other CNA (#6) failed to remove her soiled gloves and assisted CNA (#7) to apply the resident's pants and transfer the resident from the bed to a wheelchair. During an interview on 03/05/25 at 9:45 a.m., an administrative staff member (#1) confirmed she expected staff to perform hand hygiene before applying clean gloves, between glove changes, and change soiled gloves before moving on to other tasks.

Based on observation, record review, review of facility policy, review of a professional reference, and resident and staff interview, the facility failed to provide appropriate treatment and services for 1 of 1 sampled resident (Resident #4) with an indwelling urinary catheter. Failure to provide catheter cares may have contributed to or placed the resident at risk for urinary tract infections (UTIs). Findings include:Review of the facility policy titled Foley Catheter Care Policy at Mountrail Bethel Home occurred on 03/05/26. This policy, dated October 2022, stated, . It is the policy of Mountrail Bethel Home to provide catheter care to all residents that have an indwelling catheter to reduce UTIs. Catheter cares will be performed by a nursing assistant with AM [morning] and HS [hour of sleep/bedtime] cares, and as needed.Kozier & Erb's Fundamentals of Nursing: Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 892, stated, . any accumulation of secretions or excretions is irritating to the skin, harbors microorganisms, and makes an individual prone to skin breakdown and infection. Review of Resident #4's medical record occurred on all days of survey and identified an antibiotic prescribed for a urinary tract infection on four separate occasions between August 2 and November 4, 2025. The care plan stated, . CATHETER: I am at risk for complications r/t [related to] foley catheter placement. BLADDER: I am at risk for UTI . I want staff to assist with performing catheter cares BID [twice daily] and as needed . The certified nurse aide (CNA) care Kardex stated, I want staff to assist with performing catheter cares BID and as needed.Observation on 03/02/26 at 3:42 p.m. showed Resident #4 is in his room with a urinary catheter bag in his chair next to him. He stated, I put it there, so it doesn't get in my way. He was unable to confirm how often staff perform his catheter cares.During an interview on 03/04/26 at 1:20 p.m., a CNA (#4) when asked about catheter cares for Resident #4, stated, He will let us provide cares, maybe once a day and sometimes none. Review of Resident #4's medical record lacked documentation staff provided catheter cares or that the resident refused cares.During an interview on 03/05/26 at 9:45 a.m., an administrative staff member (#1) confirmed the CNA task list failed to include an area for staff to document completion of cares or resident refusa catheter cares.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to properly utilize necessary assistive devices to prevent accidents for 1 of 3 sampled residents (Resident #24) observed during a transfer. Failure to utilize a gait belt and place the walker within reach during a transfer placed the resident at risk for injury and pain. Findings include:Review of the policy titled Use of Gait Belt Policy at Mountrail Bethel Home occurred on 03/05/26. This policy, dated December 2020, stated, . It is the policy of Mountrail Bethel Home to use gait belts with residents that need assistance to ambulate or transfer for the purpose of safety.Review of Resident #24's medical record occurred on all days of survey. Diagnoses included weakness. The current care plan stated, . I have an ADL [activities of daily living] self-care deficit r/t [related to] weakness and decreased mobility . I transfer with staff Ax2 [assist of 2] and my 4WW [four wheeled walker] . I am at risk for falls .Observation on 03/02/2026 at 4:15 p.m. showed two certified nurse aides (CNAs) (#2 and #3) transferred Resident #24 from the bed to a wheelchair. Both CNAs placed their forearms under the resident's armpits and pulled the resident from a lying position to sit on the edge of the bed. Without applying a gait belt or placing the walker within reach, the CNA's placed their arms under the resident's armpits, stood the resident, held onto her pants, and pivoted the resident into the wheelchair.During an interview on 03/05/26 at 9:45 a.m., an administrative staff member (#1) stated she expected staff to utilize a gait belt and place walkers within reach during transfers.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 5 of 12 sampled residents (Resident #8, #10, #17, #19, and #25) observed during cares. Failure to practice infection control standards related to hand hygiene, catheter care, equipment disinfection, and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene Policy occurred on 12/04/24. This policy, dated December 2020, stated, . All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors . 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 Foley Catheter Care Policy occurred on 12/04/24. This policy, revised October 2022, stated, . to provide catheter care to all residents that have an indwelling catheter to reduce UTIs [urinary tract infections] . With a new moistened cloth, wipe the catheter making sure to hold the catheter in place . Review of the facility policy titled Enhanced Barrier Precautions Policy occurred on 12/04/24. This policy, revised May 2024, stated, . use of gown and gloves for use during high-risk resident care activities for residents known to be colonized or infected with a MDRO [multidrug-resistant organisms] as well as those at increased risk of MDRO acquisition (e.g., [examples] residents with wounds or indwelling medical devices . High-contact resident care activities include: . Urinary Catheter Care . Wound care . Dressing, AM [morning] or PM [evening] cares, peri [perineal] cares, transferring. Review of the facility policy titled, Mechanical Lift Policy, occurred on 12/04/24. This policy, revised December 2020, stated, . Total body lift . disinfect lift after each resident use . standing lift . disinfect lift after each resident use . - Observation on 12/02/24 at 3:57 p.m. showed two certified nurse aides (CNAs) (#6 and #7) assisted Resident #8 to the bathroom. The CNAs performed perineal cares after a bowel movement, removed their gloves and failed to perform hand hygiene. - Observation on 12/02/24 at 2:59 p.m. showed two CNAs (#6 and #7) transfer Resident #10 to the bathroom. After completing perineal cares, the CNAs removed their gloves and failed to perform hand hygiene. then without cleaning the lift removed it from the room, and placed it in the hallway storage area. - Review of Resident #17's medical record occurred on all days of survey. Diagnosis included history of urinary tract infection. The current care plan stated, . enhanced barrier precautions r/t [related to] placement of indwelling catheter . Observation on 12/02/24 at 11:32 a.m. showed an enhanced barrier precaution sign outside of Resident #17's room. Observation on 12/02/24 at 4:59 p.m. showed two CNAs (#6 and #7) performed hand hygiene, donned gowns and gloves, and entered Resident #17's room to provide catheter and incontinence cares. The CNA (#7) performed perineal cares after a bowel movement and wiped back to front. The CNA (#7) removed her gloves and without performing hand hygiene donned clean gloves, wet a washcloth, cleaned Resident #17's groin area, and with the same cloth wiped the catheter tubing, applied a clean brief, and pulled up the resident's pants. The CNA (#7) removed gloves and performed hand hygiene before exiting the room. The CNA (#7) failed to perform hand hygiene after removing soiled gloves and donning clean gloves, and failed to use a clean washcloth for cleansing the catheter tubing. - Review of Resident #19's medical record occurred on all days of survey. Diagnosis included pressure ulcer to coccyx and heel. The current care plan stated, . staff to utilize enhanced barrier precautions per policy . stage 3 PU [pressure ulcer] to my coccyx . Observation on 12/02/24 at 12:02 p.m. showed an enhanced barrier precaution sign outside of Resident #19's room. Observation on 12/02/24 showed the following: * At 3:11p.m., two CNAs (#6 and #7) entered Resident #19's room to provide incontinence cares. The CNAs performed hand hygiene, donned gloves, and without donning gowns, performed perineal cares and removed a wound dressing after a bowel movement. The CNAs removed their gloves and without performing hand hygiene, exited the room. The CNAs failed to don gowns when performing high-contact resident cares. * At 3:50 p.m., two CNAs (#6 and #7) entered Resident #19's room to provide incontinence cares. The CNAs performed hand hygiene, donned gloves, and without donning gowns, performed perineal cares. The CNAs removed their gloves and without performing hand hygiene, exited the room. The CNAs failed to don gowns when performing high-contact resident cares. - Review of Resident #25's medical record occurred on all days of survey. The current care plan stated, . Enhanced Barrier precautions r/t [related to] stasis ulcers to BLE [bilateral lower extremities] . Observation on 12/02/24 at 11:31 a.m. showed an enhanced barrier precaution sign outside of Resident #25's room. Observation on 12/03/24 at 9:55 a.m. showed Resident #25 seated in a wheelchair. Two CNAs (#6 and #7) entered Resident 25's room. The CNAs performed hand hygiene and donned gloves, and without donning gowns, assisted the resident with incontinence cares. The CNA (#7) performed bowel movement cares, removed her gloves and without performing hand hygiene, donned new gloves, applied a new brief, pulled up the resident's pants, and assisted the resident to the wheelchair. The CNAs removed their gloves, performed hand hygiene, and exited the room. Both CNAs failed to wear gowns when performing high-contact resident cares, and the CNA (#7) failed to perform hand hygiene after removing soiled gloves and before donning clean gloves. Observation on 12/03/24 at 1:13 p.m. showed Resident #25 seated in a wheelchair. A nurse (#3) entered Resident #25's room, performed hand hygiene, donned a gown and gloves, and sat on the floor and performed a dressing change to the resident's bilateral lower extremities. The nurse (#3) removed the soiled dressings from both lower extremities, removed her gloves, and without performing hand hygiene, donned new gloves. The nurse (#3) cleaned the wounds, completed the dressing change, removed her gown and gloves, performed hand hygiene and exited the room. The nurse (#3) failed to perform hand hygiene after removing soiled gloves and donning clean gloves. During an interview on 12/04/24 at 08:15 a.m., an administrative nurse (#1) confirmed she expected staff to sanitize lift equipment after each resident use. During an interview on 12/04/24 at 2:45 p.m., an administrative nurse (#1) confirmed she expected staff to perform hand hygiene after removing soiled gloves and before donning clean gloves, wipe front to back when performing cares involving bowel movements, use clean cloths for catheter cares, and for staff to wear appropriate personal protective equipment when providing high contact cares for residents in enhanced barrier precautions. 42397

Based on record review, review of facility policy, resident representative interview, and staff interview, the facility failed to notify the resident representative for 1 of 2 sampled residents (Resident #34) reviewed for falls and resident to resident altercations. Failure to notify the resident representative of a fall and resident to resident altercations does not allow the representative to be fully informed of the resident's current status. Findings include: Review of the facility policy titled Fall Protocol Policy occurred 12/04/24. This policy, dated December 2020, stated, . If the resident doesn't obtain an injury during the fall, the emergency contact will be notified as soon as possible, or next morning if the fall occurs during overnight hours. Review of the facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Employee Policy . occurred 12/04/24. This policy, revised May 2023, stated, . All alleged violations involving abuse . are reported immediately to the facility Administrator or other designated staff . in accordance with State Law through established procedures. These include: . Resident Representative . Review of Resident #34's medical record occurred on all days of survey. Diagnoses included dementia and falls. A quarterly Minimum Data Set, dated dated [DATE], identified four falls, and moderately impaired cognition. Review of Resident #34's nurse's notes identified the following: * 10/19/24 at 3:52 p.m., . Staff had heard hollering from residents [sic] room and another resident [sic] in his room and both were swinging there [sic] arms. Resident in w/c [wheelchair] in room stated the other resident hit him in face. No injuries noted at this time. Will monitor. * 11/17/24 at 6:38 p.m., . Resident yelling, 'help, help', CNA [certified nurse aide] walked into resident's room and noticed that resident was sitting upright on the floor with legs extended out towards toilet. Denying hit head. Resident stated, 'I was trying to sit in w/c [wheelchair] after coming back from the bathroom.' Vital signs WDL [within defined limits] per resident's baseline. No c/o [complaints of] pain or discomfort. MD [medical doctor] notified. During an interview on 12/02/24 at 4:46 p.m., Resident #34's representative stated the resident had multiple falls and was not sure the facility had contacted him for all falls. He further stated the facility did not contact him regarding the incident between Resident #34 and the other resident, he was told by Resident #34's brother who also resides in the facility. During an interview on 12/03/24 at 3:10 p.m., an administrative nurse (#2) confirmed the facility failed to notify Resident #34's representative of the resident to resident altercation until he called the facility to ask about it. During an interview on 12/03/24 at 3:33 p.m., an administrative nurse (#1) confirmed the facility failed to notify Resident #34's representative about the resident's fall on 11/17/24, and she expected staff to notify the resident representative with all falls, and resident to resident altercations.

Based on review of the facility reported incident and investigation documents, record review, review of facility policy, and staff interview the facility failed to protect the residents' right to be free from physical abuse and psychosocial harm for 1 of 2 sampled residents (Resident #34) and 1 supplemental resident (Resident #3) who experienced abuse by another resident. Failure to ensure an environment free from abuse placed Residents #3, #34, and other residents at risk for abuse, fear, anxiety, and/or psychosocial harm. This citation is considered past non-compliance based on review of the corrective action the facility implemented following the incident. Findings include: The surveyor determined a deficient practice existed on 10/19/24 and 11/04/24. The facility implemented and completed corrective action on 11/04/24. Review of the facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Employee Policy . occurred on 12/04/24. This policy, revised May 2023, stated, . Abuse, Neglect, exploitation, mistreatment . is prohibited. Physical Abuse is defined as the willfully hitting, slapping, pinching, kicking, etc. Review of the facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Prevention Facility Policy . occurred on 12/04/24. This policy, revised May 2023, stated, . Each resident has the right to freedom from all forms of abuse . Residents must not be subjected to abuse by anyone including, but not limited to . other residents . Resident to Resident Altercations: . Altercations that must be reported in accordance with regulations include ay [sic] willful action that results in physical injury, mental anguish, or pain . - Review of Resident #3's medical record occurred on all days of survey. A quarterly Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognition. Review of Resident #3's nurses notes identified the following: * 11/02/24 at 5:00 p.m., . [Resident #3] was in her room while staff was down the hall from her, [Resident #17] had entered [Resident #3's] room, the resident had yelled out for help so staff ran to her room and when staff entered the resident room [Resident #17] had [Resident #3's] arm grasped with his one hand and was hitting the resident with his other hand, staff quickly grabbed [Resident #17] to keep him from making contact with the resident, staff tried asking him to leave the room but he would not listen or leave and continued attempting to assault the resident, staff had to physically remove [Resident #17] from the residents room . staff tried asking ifthe[sic] resident was harmed or hurt in anyway but [Resident #3] was overwhelmed with anxiety and was very upset so staff left the resident so she could calm down. * 11/04/24 at 1:32 p.m., stated, . Incident was reported to ND HHS [North Dakota Department of Health and Human Services] due to resident being hit by another resident. - Review of Resident #34's medical record occurred on all days of survey. A quarterly MDS, dated [DATE], identified moderately impaired cognition. Review of Resident #34's nurses notes identified the following: * 10/19/24 at 3:52 p.m., stated, . Staff had heard hollering from [Resident #34's] room and [Resident #17] in his room and both were swinging there [sic] arms. Resident in w/c [wheelchair] in room stated [Resident #17] hit him in face. No injuries noted at this time. Will monitor. * 10/22/24 at 4:27 p.m., stated, . Incident was reported to ND HHS. Maintenance has been notified to place a yellow strip in front of resident's door to try divert other resident from wanting to enter his room. Review of the facility investigation report occurred 12/04/24. This report, dated 10/19/24, stated, . Staff watched other resident enter resident's room, and got up to remove the other resident from [Resident #34's] room. While on their way to his room they heard [Resident #34] say 'get the hell out of my room.' by [sic] the time the CNA got to his room CNA observed both resident's swinging their arms and observed the other resident hit [Resident #34] on the lip one time. The report included a statement from a CNA (#1), which stated, . saw [Resident #17] enter [Resident #34's] room . observed [Resident #17] hit [Resident #34] in the lip one time. Based on the following information, non-compliance at F600 is considered past non-compliance. The facility implemented corrective actions as follows: * The interdisciplinary team met to problem solve and implement changes and interventions for resident care and safety. * Implemented a safety plan addressing the behaviors of Resident #17. * Notified medical director and psychiatric provider for Resident #17 of the incidents. * Notified resident representatives of the incident and actions implemented. * Education provided to all staff on safety plan and behavioral interventions for Resident #17.

Based on review of the facility reported incidents (FRI), record review, review of facility policy, and staff interview, the facility failed to report incidents of abuse to the State Survey Agency (SSA) for 1 of 1 sampled resident (Resident #34) and 1 supplemental resident (Resident #3) who experienced physical abuse. Failure to report physical abuse in the prescribed time frame does not comply with regulations established to protect residents. Findings include: Review of the facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Employee Policy occurred on 12/04/24. This policy, revised May 2023, stated, . Abuse, Neglect, exploitation, mistreatment . is prohibited. To assist our facility's staff members in recognizing incidents of abuse, the following definitions of abuse are provided: . Immediately: Means as soon as possible, in absence of a shorter State time frame requirement, but not later than . 24 hours if the events that cause the allegation . do not cause serious bodily injury. Physical Abuse is defined as the willfully hitting, slapping, pinching, kicking, etc. alleged violations and results of all investigations must be reported to the administrator of the facility and/or other designees in accordance with state law AND the state survey and certification agency. Review of the facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Prevention Facility Policy occurred on 12/04/24. This policy, revised May 2023, stated, . Each resident has the right to freedom from all forms of abuse . Residents must not be subjected to abuse by anyone including, but not limited to . other residents . All alleged violations involving . abuse . will be reported immediately . to the administrator of the facility and to other officials in accordance with State law through established procedures (including the State survey and certification agency). Resident to Resident Altercations: . Altercations that must be reported in accordance with regulations include ay [sic] willful action that results in physical injury, mental anguish, or pain . - Review of Resident #3's medical record occurred on all days of survey. A quarterly Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognition. Review of Resident #3's nursing notes identified the following: * 11/02/24 at 4:25 p.m., . CNA [certified nurse aide] reported that [Resident #17] was near resident's door and the two [Resident #3 and #17] got into an altercation. CNA also reported that [Resident #17] tried hitting her. When asking [Resident #3] what happened she was not able to answer due to the amount of anxiety she was having. No signs of injuries that nurse writing can observe. Will reapproach when she is more calmed down. * 11/02/24 at 5:00 p.m., . [Resident #3] was in her room while staff was down the hall from her, [Resident #17] had entered the resident's room, the resident had yelled out for help so staff ran to her room and when staff entered the resident room [Resident #17] had [Resident #3's] arm grasped with his one hand and was hitting the resident with his other hand, staff quickly grabbed [Resident #17] to keep him from making contact with the resident, staff tried asking him to leave the room but he would not listen or leave and continued attempting to assault the resident, staff had to physically remove [Resident #17] from the residents room . staff tried asking ifthe[sic] resident was harmed or hurt in anyway but [Resident #3] was overwhelmed with anxiety and was very upset so staff left the resident so she could calm down. * 11/04/24 at 1:32 p.m., . Incident was reported to ND HHS [North Dakota Department of Health and Human Services] due to resident being hit by another resident. Two days after the altercation. - Review of Resident #34's medical record occurred on all days of survey. A quarterly MDS, dated [DATE], identified moderately impaired cognition. Review of Resident #34's nurses notes identified the following: * 10/19/24 at 3:52 p.m., . Staff had heard hollering from [Resident #34] room and another resident in his room and both were swinging there [sic] arms. [Resident #34] in w/c [wheelchair] in room stated the other resident hit him in face. No injuries noted at this time. Will monitor. * 10/22/24 at 4:27 p.m., . Incident was reported to ND HHS. Maintenance has been notified to place a yellow strip in front of resident's door to try divert other resident from wanting to enter his room. Three days after the altercation. During an interview on 12/04/24 at 12:30 p.m., administrative nurses (#1 and #2) confirmed the facility failed to report the incidents between Residents #3, #17, and #34 to the SSA within 24 hours.

1. Based on observation, record review, review of manufacturer's instructions for use, and staff interview the facility failed to ensure staff followed standards of practice for 1 of 2 residents (Resident #34) observed for insulin preparation and administrations. Failure to administer rapid-acting insulin within the time specified by the manufacturer may result in a hypoglycemic (low blood sugar) reaction. Findings include: Review of Important safety information for NovoLog (rapid acting insulin), found at https://www.novolog.com occurred on 12/04/24 and stated, and About NovoLog(R) Rapid-Acting Insulin ., occurred on 12/04/24 and stated, Novolog starts acting fast. Eat a meal within 5 to 10 minutes after taking it. - Review of Resident #34's medical record occurred on 12/04/24. Current physician's orders included Novolog Insulin; Inject 3 unit subcutaneously three times a day. Observations on 12/04/24 showed the following: * 11:04 a.m., a nurse (#3) prepared and administered 3 units of NovoLog insulin to resident #34. * 11:45 a.m., Resident #34 was seated in the dining room without access to juice and dessert until 41 minutes after receiving rapid-acting insulin. The facility failed to follow manufacturer's instructions for rapid-acting insulin related to administration and timing of the meal for Resident #34. During an interview on 12/04/24 at 2:37 p.m., two administrative staff members (#1 and #2) stated, our expectation is the nurse should administer insulin between 11:00 a.m. and 12:00 p.m. as stated on the medication administration record. 2. Based on observation and staff interview, the facility failed to ensure 1 of 1 treatment cart contained medications prescribed and labeled for residents of the facility. Failure to store and/or dispense medications not intended for residents of the facility has the potential to result in a medication error. Finding include: Observations on 12/04/24 at 10:00 a.m. showed a medication cup with several loose tablets and capsules in the corner of the first drawer of the treatment cart. During an interview on 12/04/24 at 10:00 a.m., a staff nurse (#3) stated, oh, those are mine, I need to remember to take them. The nurse (#3) removed the medication cup from the cart and put it in her pocket. During an interview on 12/04/24 at 2:37 p.m., two administrative staff members (#1 and #2) stated, personal medications should not be stored in the medication or treatment carts.

Based on observation, record review, review of facility policy, review of a professional reference, and staff interview, the facility failed to utilize the assistive devices necessary to prevent accidents for 1 of 4 sampled resident (Resident #19) observed during a transfer. Failure to use a gait belt during transfers has the potential to place residents at risk of falls with/without injury. Findings include: Review of the facility policy titled Use of Gait Belt, occurred on 12/04/24. This policy, dated December 2020, stated, . use gait belts with residents that need assistance to ambulate or transfer for the purpose of safety . Physical Therapy will assess residents upon admission and determine their need for a gait belt . [the facility] will have designated gait belts for each resident who requires one . All employees will receive education on the proper use of a gait belt . Review of Resident #19's medical record occurred on December 4, 2024. The care plan, stated, . I am at risk for falls related to physical decline . I pivot transfer with assist of 1 staff for transfers . use gait belt for safety . Observations on 12/03/24 showed the following: * At 3:56 p.m., a staff nurse (#3) and a certified nurse aide (CNA) (#5) transferred Resident #19 from the wheelchair to the bedside commode. Both staff members (#3 and #5) placed their hands under the Resident's arms and lifted her to a standing position. The staff members (#3 and #5) failed to use a gait belt during the transfer. * At 4:10 p.m., while transfering Residnt #19 from the commode both staff members (#3 and #5) again placed their hands under Resident #19's arms and lifted her to a standing position. Resident #19 lost her balance, supported herself by leaning on the arms of the wheelchair, and required staff assistance to sit back down. The staff members (#3 and #5) failed to use a gait belt during the transfer. During an interview on 12/03/24 at 8:15 a.m., an administrative nurse (#1) stated she expected staff to use a gait belt during transfers.

Based on observation and staff interview, the facility failed to ensure safe and secure storage of medications in 1 of 2 medication/treatment carts observed. Failure to store all medications securely may result in unauthorized access to medications. Findings include: On 12/02/24 at 11:51 a.m., Observation showed staff nurse (#4) unlock the treatment and walk away to administer insulin. The staff nurse (#4) left the treatment cart unlocked and unattended for five minutes by the nurse's station out of the nurses' view with visitors, staff members, and residents present. During an interview on 12/04/24 at 2:37 p.m., two administrative staff members (#1 and #2) stated, it is our expectation that the carts be locked when out of sight.

Based on observation, record review, review of facility policies, and staff interview, the facility failed to follow standards of infection control for 2 of 3 sampled residents (Residents #1 and #2) observed during toileting cares. Failure to follow infection control standards has the potential for infections to residents. Findings include: Review of the facility policy titled Hand Hygiene Policy occurred on 01/11/24. This policy, dated December 2020, stated, .2. Hand hygiene is indicated and will be performed. 6. Additional considerations: a. 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 facility policy titled Perineal Care Policy occurred on 01/11/24. This policy, dated December 2020, stated, . 2. Gather supplies needed. v. Gloves, and other relevant personal protective equipment. 6. Perform hand hygiene and put on gloves. 8.a. Cleanse buttocks and anus, front to back; vagina to anus in females. using a separate washcloth or wipes. 15. Remove gloves and discard. Perform hand hygiene. Review of facility policy titled Mechanical lift Policy occurred on 01/11/24. This policy, revised December 2020, stated, . Procedure: . 2. Standing lift.b. Wash hands before and after procedure. Review of Resident #1's medical record occurred on 01/11/24. The care plan stated, . I am at risk for UTI's [sic] [urinary tract infections] . I am dependent on staff. with peri cares after toileting and episodes of incontinence . During an observation on 01/11/24 at 1:10 p.m., two certified nurse aides (CNAs) (#2 and #3) assisted Resident #1 to the commode using a mechanical stand lift. The CNA (#2) performed incontinence cares by wiping from back (anus) to front. Without removing the soiled gloves, the CNA (#2) wiped the resident's groin area with a separate wipe. The CNA (#2) applied a clean brief, pulled up the resident's pants, transferred the resident back into the wheelchair, and removed the sling. The CNA (#2) failed to remove or change the gloves and perform hand hygiene before completing other tasks. Review of Resident #2's medical record occurred on 01/11/2024. The care plan stated, . I am at risk for UTI's [sic] r/t [related to] bladder incontinence . I am dependent on staff. with peri cares after toileting and episodes of incontinence . During an observation on 01/11/24 at 3:10 p.m., two CNAs (#2 and #4) assisted Resident #2 to the commode using a mechanical stand lift. The CNA (#2) performed incontinence cares (bowel) by wiping from back (anus) to front. The CNA (#2), without removing the soiled gloves or performing hand hygiene, wiped the resident's groin area with a separate wipe. The CNA (#2) then applied a clean brief, pulled up resident's pants, transferred the resident back into the wheelchair, and removed the sling. The CNA (#2) failed to remove or change the gloves and perform hand hygiene before completing other tasks. During an interview on 01/11/24 at 3:10 p.m., an administrative staff nurse (#1) stated she expected staff to use proper infection control practices when providing perineal cares.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 12/08/22. Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 2 of 4 sampled residents (Resident #24 and #237) observed during dressing changes and 1 supplemental resident (#18) with Covid 19. Failure to practice infection control standards related to hand hygiene during dressing changes and use of personal protective equipment (PPE) has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Clean Dressing Change Policy and Procedure at Mountrail Bethel Home occurred on 11/16/23. This policy, dated December 2020, stated, . remove the existing dressing . Remove gloves . Wash hands and put on clean gloves . cleanse the wound . Wash hands and put on clean gloves . Review of the facility policy titled COVID-19 Policy at Mountrail Bethel Home occurred on 11/15/23. This policy, dated May 2023, stated, . If a resident tests positive for COVID-19, immediately bring them to their room, close their door, place a PPE cart outside their door and hang a Droplet Precautions sign on the outside of the door. 2. All staff who enter the residents' room shall wear an: n95 respirator, gown, gloves and face shield . HAND HYGIENE DURING DRESSING CHANGE - Observation on 11/15/23 at 9:50 a.m. showed a licensed nurse (#11) donned gloves and removed Resident #237's wound dressing from the right ankle. Without changing gloves or performing hand hygiene, the nurse cleansed the wound with normal saline and applied a new dressing. The nurse changed her gloves without performing hand hygiene, provided frontal perineal care for the resident, again changed her gloves without performing hand hygiene, and applied a dressing to Resident #237's coccyx. The nurse failed to remove her gloves and perform hand hygiene after removing a dressing, cleansing the wound, and performing perineal care. - Observation on 11/15/23 at 2:30 p.m. showed a licensed nurse (#11) donned gloves and performed bowel incontinence care for Resident #24. The resident did not have a dressing on the sacrum. Without changing gloves or performing hand hygiene after perineal care, the nurse picked up the dressing and attempted to open it when the surveyor stopped the nurse (#11) and requested she remove her gloves and perform hand hygiene before continuing with the dressing change. PPE for Covid 19 - Observation on 11/15/23 at 12:40 p.m. showed Resident #18's room with a PPE cart outside of the room, a sign on top of the cart stated, Stop Droplet Precautions Everyone must . Make sure their eyes, nose and mouth are fully covered before room entry . A licensed nurse (#2) applied a gown, a N95 respirator mask over her surgical mask, and gloves, before entering Resident #18's room. The nurse (#2) failed to apply a face shield before entering the room. During an interview on 11/15/23 at 12:45 p.m., two certified nurse aides (#12 and #13) stated they did not wear a face shield in Resident #19's room while providing care as the PPE cart did not contain face shields. During an interview on 11/16/23 at 12:30 p.m., an Infection Preventionist nurse (#14) stated she expected staff to remove gloves and perform hand hygiene after removing a dressing and after perineal cares. She also stated it is not acceptable to wear a N95 mask over a surgical mask, and she expected staff to wear a face shield in a Covid positive room.

Based on observation, review of facility policy, and staff interview, the facility failed to provide care for 1 of 10 sampled residents (Resident #13) and 1 supplemental resident (#17) in a manner and environment that maintained, enhanced, and respected each resident's dignity. Failure to wait for permission prior to entering a resident's room and ensure a resident's private body parts are not exposed does not preserve the resident's personal dignity and/or enhance their quality of life and placed them at risk of embarrassment and/or emotional harm. Findings include: Review of the facility policy titled, Confidentiality, Privacy, and Dignity, occurred on 11/16/23. This policy, revised 07/19/16, stated, . All staff will knock before entering a resident/patient's room and allow resident/patient's privacy when receiving treatment and caring for their personal needs. - During an observation on 11/14/23 at 4:06 p.m., two certified nurse aides (CNAs) (#3 and #4) transferred Resident #13 into bed before providing toileting cares. Resident #13 indicated he scratched his lower stomach and voiced pain/discomfort when the CNAs (#3 and #4) cleansed the area. Resident #13 laid on the bed, exposed from mid-chest to knees, when one of the CNAs (#4) exited the room to find the nurse. A few minutes later, the nurse (#2) knocked, announced herself, and entered the room without waiting for permission to enter. The other CNA (#3) covered Resident #13's groin with a towel after the nurse entered the room. During an interview on 11/18/23 at 12:55 p.m., an administrative nurse (#1) indicated she expects staff to ensure the resident's dignity while providing personal cares. Review of the facility policy titled, Helping a resident with Toileting Policy and Procedure occurred on 11/16/23. This policy, dated December 2020, stated, . It is the practice of this facility to assist residents with toileting needs to maintain the resident's dignity. help the resident to the bathroom . assist resident with clothing and assist them back to their chair . Observations of Resident #17 showed the following: - 11/13/23 at 3:02 p.m., the resident sitting in a chair in the lobby with urine soaked pants during a visit with a staff member. A nurse, (#2) assisted the resident to the bathroom and changed the soiled pants. -11/14/23 at 3:25 p.m., the resident sitting in a chair in the lobby with urine soaked pants while other residents, staff, and visitors walked by. A nurse (#2) assisted the resident to the bathroom and changed the soiled pants. -11/15/23 at 3:05 p.m., the resident sitting in a chair in the lobby with urine soaked pants while other residents, staff, and visitors walked by. A nurse, (#2) assisted the resident to the bathroom and changed the soiled pants. During an interview on 11/16/23 at 9:47 a.m., an administrative nurse (#1) indicated she expected staff to toilet the resident timely. 39685

Based on observation, record review, review of facility policy, and staff interview, the facility failed to assess residents for self-administer of medications for 1 of 1 sampled residents (Resident #30) observed with medications in the dining room. Failure to evaluate residents' ability to safely self-administer medications may result in medication errors and/or harm to the residents. Findings include: Review of the policy titled, Self-Administered Medications occurred on 11/16/23. This policy, implemented November 2020, stated, . It is the policy of Mountrail Bethel Home to evaluate and allow a resident to self-administer medications after the interdisciplinary team has determined which medications may be self-administered safely. According to the self-administer medications assessment, a decision to allow the resident to self-administer medications or to discontinue self-administration of medications will be determined. Review of Resident #30's medical record occurred on all days of survey. The record lacked an assessment for self-administration of medications and/or a physician's order permitting the resident to do so. The quarterly Minimum Data Set (MDS), dated [DATE], identified severe cognitive deficits. Observation showed the following: - 11/14/23 at 7:57 a.m., a licensed nurse (#2) stated, (Resident #30) here are your meds [medication]. The nurse (#2) set the medication cup on the table and left the dining room before the resident took the medications. * 11/14/23 at 8:12 a.m., Resident #30 ate breakfast in the dining room with an empty medication cup next to her plate. * 11/15/23 at 7:50 a.m., Resident #30 ate breakfast in the dining room. The cup next to her plate still contained medications. The nurse (#2) stood next to her medication cart in the next room, out of sight of the resident. During an interview on 11/15/23 at 8:55 a.m., a nurse (#2) indicated she left medications on the table for Resident #30 as they can self-administer [their medications]. During an interview on 11/15/23 at 2:20 p.m., an administrative nurse (#1) confirmed, [Resident #30] cannot self-administer their medication. 31725 - Observation on 11/14/23 at 7:57 a.m. showed a licensed nurse (#2) stated, (Resident #30) here are your meds [medication] the nurse (#2) set the medication cup on the table and left the dining room.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to notify the physician of a change of condition for 1 of 1 sampled resident (Resident #16) with a new pressure ulcer. Failure to promptly notify the physician of the pressure ulcer limited their ability to make informed decisions regarding the resident's medical care. Findings include: Review of the facility policy titled Wound Treatment Management occurred on 11/15/23. This policy, dated December 2020, stated, To promote wound healing . provide evidence-based treatments in accordance with current standards of practice and provider orders . in the absence of treatment orders, the licensed nurse will notify the physician next business day to obtain treatment orders . Findings include: Review of Resident #16's medical record occurred on all days of survey. A progress note, dated 11/13/23 at 8:18 p.m., identified, . CNA [certified nurse aide] to nurse 6 a.m. - 6 p.m. shift on Friday, 11/10/23, that resident has a sore to right buttocks . this nurse assessed area now, 3 x [times] 3 cm [centimeter] sore (Lshaped) to right buttocks. skin has sheared away . calmoseptine [a skin protectant] seems to have minimal affect . concern note sent to physician . During an interview on 11/15/23 at 10:22 a.m., an administrative nurse (#1) reported staff wrote a concern note for the physician on Friday 11/10/23 addressing Resident #16's pressure ulcer and put it in his in-box, but the physician did not receive the note until Monday 11/13/23. During an interview on 11/16/23 at 9:47 a.m., an administrative nurse (#1) reported the facility is re-evaluating the current process for physician notification. The nurse (#1) stated she expected staff to evaluate/treat Resident #16's pressure ulcer in a timely manner.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 12/08/22. Based on observation, record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 13 sampled residents (Resident #9 and #13). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2023, pages K-10 and K-12 stated, . FEEDING TUBE Presence of any type of tube that can deliver food/nutritional substances/fluids/medications directly into the gastrointestinal system. Examples include, but are not limited to, Asiatic tubes, gastrostomy tubes, jejunostomy tubes, percutaneous endoscopic gastrostomy (PEG) tubes. Coding Tips for K0520B Only feeding tubes that are used to deliver nutritive substances and/or hydration during the assessment period are coded in K0520B. - Review of Resident #9's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], identified the presence of a feeding tube. During an observation on 11/13/23 at 2:06 p.m., two certified nurse aides (CNAs) (#4 and #16) transferred Resident #9 on and off the toilet. Observation showed Resident #9 did not have a feeding tube in place. During an interview on 11/13/23 at 3:27 p.m., an administrative nurse (#1) confirmed staff marked the tube feeding in error. - Review of Resident #13's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], identified the presence of a feeding tube. During an observation on 11/14/23 at 4:06 p.m., two CNAs (#3 and #4) transferred Resident #13 into bed before providing toileting cares. Observation showed Resident #13 did not have a feeding tube in place. During an interview on 11/15/23 at 11:45 a.m., a licensed staff member (#8) confirmed staff marked the tube feeding in error. 31725

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide an ongoing program of meaningful activities designed to meet the interests and physical, mental, and psychosocial well-being for 1 of 13 sampled residents (Resident #26) dependent on staff for activities. Failure to provide meaningful activities for residents limited Resident #26's ability to reach his highest practicable level of physical, mental, and psychosocial well-being. Findings include: Review of the facility policy titled Activity Program occurred on 11/16/23. This policy, revised April 2023, stated, . It is the policy of Mountrail Bethel Home to have a planned and meaningful activity program which meets the needs and interests of the residents. Assessment will be completed . upon admit to facility, and on an ongoing basis thereafter to identify their activity needs and interests. Activity program will be developed based off these assessment findings. Activities will be available during the day, in the evenings and on the weekends. Review of Resident #26's medical record occurred on all days of survey. The current care plan stated, . I . enjoyed . farming . visiting about flight. Baseball . archery and gardening . carpentry work . When there are programs about farming, invite me. When there are programs about flying, invite me. I maybe open to playing cards and maybe bingo. I like music, especially gospel. Please invite me to listen. I enjoy most programs on METV and I especially like shows such as Gunsmoke. I enjoy going outside for fresh air when the weather permits. Observations throughout the survey showed Resident #26 sitting/dozing in a recliner in the lounge with the tv on in the background and not participating in any individual or group activities. The activity log, date October 1-November 14, 2023, showed Resident #26 sat in the lounge with the tv on on 36 occasions. Resident #26 participated in three one-on-one activities and 11 group activities within the 45 day period. During an interview on 11/16/23 at 12:12 p.m., an activities staff member (#9) agreed staff failed to engage Resident #26 in a meaningful activity program which met his needs/interests.

Based on review of the Payroll Based Journal (PBJ) Staffing Data Report, information from the complainant, review of nurse staffing schedules, and staff interview, the facility failed to provide the services of a licensed nurse for 24 hours a day, seven days a week, on 48 of 168 days of nursing schedules ([DATE]-[DATE]) reviewed. Failure to schedule a nurse 24 hours a day may result in inefficient or lack of coordination of care/services, limited ability to promptly respond to residents' needs or administrative concerns, and could lead to confusion and/or an adverse outcome in an emergency; therefore, endangering residents' health, safety and well-being. During the on-site recertification and complaint survey, the team determined a potential Immediate Jeopardy (IJ) situation existed on [DATE] at 4:19 p.m. The IJ potential resulted from review of the nurse staffing schedules indicating lack of licensed nurse coverage 24 hours a day. This finding placed residents in immediate danger due to the lack of a licensed nurse present to assess and manage resident health and safety. * [DATE] at 1:45 p.m., During an interview, an administrative nurse (#9) and an administrative staff member (#13) stated the practice to staff a medication aide in place of a nurse from 6:00 p.m. to 10:00 p.m. started sometime in the past year per a prior administrative staff member's suggestion, so management or other nurses would not have to cover those hours. They stated the hospital emergency room (ER) nurses were available to call if needed. The administrative staff member (#13) stated, We have changed that practice now, and will never staff that way again. We have fixed the schedule right away. * [DATE] at 4:19 p.m., The survey team contacted the State Survey Agency (SSA) to report the findings and discuss potential IJ. * [DATE] at 5:15 p.m., The SSA contacted the survey team after discussion with the CMS (Centers for Medicare & Medicaid Services) location and verified the presence of IJ. * [DATE] at 5:28 p.m., The survey team notified the assistant director of nursing (ADON), who notified the administrator and director of nursing by phone/email, of the IJ situation, provided them with the IJ template, and requested they develop a plan for removal of the immediate jeopardy. * [DATE] at 6:44 p.m., The ADON presented the IJ removal plan which the survey team reviewed and accepted. The ADON stated the current schedule ended on [DATE] and there were no medication aides scheduled to work alone for that time period. Review of the schedule confirmed this statement. * [DATE] at 10:13 a.m., The survey team verified the facility carried out the IJ removal plan and the survey team removed and reduced the IJ situation from a scope/severity of L or a scope/severity of F. * [DATE] at 2:58 p.m., The SSA notified the CMS location of the removal of IJ. Findings include: Review of the PBJ Staffing Data Report, for the quarter of [DATE] - [DATE], showed the facility triggered for Failed to have Licensed Nursing Coverage 24 Hours/Day on four days. Information provided by the complainant stated concern for cares and assessments of residents as the complainant noted only a medication aide and certified nurse aides scheduled at night, but no nurse. The facility provided a copy of the nurse staffing schedules for the time period of [DATE] - [DATE]. A review of the schedules identified 48 days the facility scheduled a medication aide instead of a licensed nurse during a portion of the 24-hour day. The facility lacked nurse coverage from 6:00 p.m. to 10:00 p.m. on 45 days and from 7:00 p.m. to 10:00 p.m. on three days. The last day scheduled without a nurse for 24 hours was [DATE]. Medical record review of the past four months identified six of 12 sampled residents (Resident #18, #24, #25, #27, #28, and #29) with falls with or without injuries, a resident (#29) on intravenous (IV) antibiotics per a PICC line (peripherally inserted central catheter, a form of IV access) who pulled out the PICC line twice, two residents (#21 and #28) with wander guards of which one resident eloped, and one resident on comfort cares who expired. The nurse staffing schedule showed at the time of the resident's death, only one medication aide and five certified nurse aides scheduled, with one administrative nurse on-call. During an interview on [DATE] at 5:28 p.m., the ADON stated when a medication aide was scheduled without a nurse present, the medication aide was supposed to call one of the nurse managers before contacting a hospital nurse. The ADON stated, I don't think the ER nurse ever had to come over to the facility. We would help per phone or come in. During an interview on [DATE] at 6:09 p.m., a certified nurse aide/medication aide (#14) who worked evenings and nights, stated the last time she worked without a nurse present was last week from ,d+[DATE] p.m. We were told that a nurse from the hospital was available if needed, but were told to call the nurse on-call first. The medication aide clarified the on-call nurse as the facility director of nursing (DON), ADON, or other nurse manager. She stated she never called a hospital nurse for assistance as she always called the DON or ADON first, for example, when a resident needed an as-needed (PRN) medication or questions from family members.

[CONDITION(S)] TREATMENT 1. Based on record review, review of facility policy, and staff interview, the facility failed to provide care in accordance with professional standards for 1 of 2 sampled residents (Resident #23) with a urinary tract infection ([CONDITION(S)]). Failure to promptly treat a resident's urinary tract infection caused pain, discomfort, need for further treatments, and the potential for a serious bloodstream infection. Findings include: A review of the facility's Suspected [CONDITION(S)] Protocol Form occurred on 12/08/22. This protocol, revised 09/30/2020, stated, . With Catheter: MUST have TWO of the following symptoms, Fever 100.4 degrees Fahrenheit (F) or above, new or increased incontinence, urgency, dysuria [painful urination] foul smelling urine, chills, frequency, suprapubic or flank pain/tenderness, change or worsening of mental or functional status. If resident meets the criteria for [CONDITION(S)] protocol, push fluids and administer UtyMax [a cranberry based supplement which provides the nutrients for the dietary management and prevention of recurrent urinary tract infections] BID [twice a day] for 72 hours. Symptoms shall be reassessed each shift for presence of the above symptoms. At the end of 72 hours IF symptoms persist, obtain a urinalysis and review results with physician. Review of the facility's policy titled Lab and Radiology Services occurred on 12/08/22. This policy, implemented December 2020 stated, . 4. Results of lab and /or radiology are printed to the nurse's station printer, and results need to be relayed onto the provider to be reviewed. Review of Resident #23's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current care plan stated, . Urinary: I am at risk for [CONDITION(S)]'s r/t [related to] placement of foley catheter. I want to remain free of [CONDITION(S)] and other complications through review date. I want staff to assist in performing catheter cares BID and as needed. I want staff to encourage me to drink adequate amounts of fluid throughout the day. I want staff to monitor for s/sx [signs and symptoms] of [CONDITION(S)] and report to nurse/MD [medical doctor] as indicated. Initiate [CONDITION(S)] protocol when indicated per policy. During an interview on 12/05/22 at 1:20 p.m., Resident #23 stated she had a [CONDITION(S)] and was on an antibiotic that took them a while to start because they said they were waiting for the culture to come back. The resident reported a history of UTIs. Record review showed [CONDITION(S)] treatment on 09/23/22 and 10/28/22 and frequent pain. Resident #23's progress notes showed the following: * 11/22/22 at 09:04 a.m., . [CONDITION(S)] Protocol completed and urine sample has been sent to the lab. Urine continues to be cloudy and foul smelling. Resident had complaint of suprapubic and flank pain on HS [hour of sleep]. * 11/22/22 at 2:35 p.m., . Concern slip back from Dr. [name] . UA collected and sent to lab and results sent to Dr. [name]. * 11/22/22 at 3:40 p.m., . Labs have been reviewed by Dr. [name]. He is waiting until the culture come [sic] back before new orders. * 11/29/22 at 12:10 p.m., . Culture back and Dr. [name] reviewed and placed resident on [MEDICATION(S)] 100mg 2x daily times 5 days. * 11/30/22 at 8:10 p.m., . Resident very lethargic and moaning. Vital signs taken and BP [blood pressure] very low at 74/45, pulse 88, Temp 97.7, resp 24, O2 [oxygen saturation] 96%. Resident was just started on [MEDICATION(S)] for [CONDITION(S)]. TC [telephone call] to on call provider [name] PA [physician's assistant] regarding situation. Orders received to give Bolus of 1 liter NS [normal saline] IV [intravenously] now. * 11/30/22 at 9:45 p.m., . IV infusion complete. Vital signs are as follows, BP 87/42, Resp 20, Pulse 89, Temp 98.4, 93% O2 RA. Disconnected IV tubing from arm. TC to [name] PA with results . * 12/01/22 at 6:23 a.m., . Foley catheter changed as balloon had deflated. New 16FR indwelling foley catheter inserted with immediate return of urine. Urine dark yellow in color. BP checked et [and] was 113/59-P [pulse] 88 . O2 sat 99% on RA [room air]. * 12/01/22 8:57 a.m., . C/o [complained of] lower backpain and tylenol given at breakfast. Tearful at times. vitals-98.3-62-20 109/54 95% on room air. Remains in bed per request. Appetite fair. On antibiotic therapy and no adverse reaction noted. Fluids encouraged. Foley catheter draining dark yellow urine. * 12/01/22 at 11:34 a.m., . Resident was seen by Dr. [name] for C/O back pain. Last evening had a very low BP and received fluids. Resident has not felt well the last couple of days and has been in bed. Order for CBC [complete blood count] and a CMP [comprehensive metabolic panel]. * 12/02/22 at 2:28 a.m., . Resident in better spirits during HS cares. No crying noted and states she had said she wanted to die but if she thinks she is doing better she will feel better. She states that she is feeling better and would like to play on tablet and sit in wheelchair. Urine continues to be dark amber in color. No sediment noted. No s/s of ADR [adverse drug reaction] noted to starting [MEDICATION(S)]. vitals WNL[within normal limits]. Record review identified the urine culture report as final on 11/24/22; however, facility staff failed to implement interventions until 11/29/22 (five days later). The facility failed to follow up on labs and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . WOUND ASSESSMENT AND TREATMENT 2. Based on observation, record review, review of facility policy, and staff and resident interview, the facility failed to provide treatment and care in accordance with professional standards for 1 of 1 sampled residents (Resident #2) with [CONDITION(S)] (excess fluid accumulation in the body tissues) and a new surgical wound. Failure to utilize compression stockings or wraps as ordered for [CONDITION(S)] and assess wounds may result in worsening [CONDITION(S)], skin breakdown, or infection. Findings include: Review of facility policies occurred on 12/08/22. The Elastic Stocking/Anti-Embolism/Ted Hose Policy, dated December 2020, stated, . A provider's order must be obtained. Ted hose should be applied in the morning and taken off at bedtime unless otherwise ordered. The Wound Treatment Management Policy, dated December 2020, stated, . Policy: to promote wound healing of various types of wounds. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. Wounds will be assessed weekly, every Tuesday, and documented on the wound Assessment Sheet within the Wound Binder at the nurse's station. Any concerns will be forwarded to the provider. Review of Resident #2's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility completed a significant change Minimum Data Set (MDS) on 11/07/22 for weight gain and the addition of a diuretic. The current care plan stated, . Excess Fluid Volume: I am at risk for [CONDITION(S)]. I want to have minimal [CONDITION(S)] and any presence of [CONDITION(S)] to be well managed. I need assisted [sic] with putting on my ted stocking/ace wraps in the morning and off at bedtime. Interviews and observations showed the following: * 12/05/22 at 12:46 p.m., Resident #2 stated her toenails were removed. The resident stated her toes were sore and that her stockings rubbed on them. She liked when they wrapped them, but she must ask for that. Observation showed dried blood on her stockings, and no compression stockings or wraps on lower extremities. * 12/05/22 at 03:50 p.m., two nurses (#10 and #11) applied dressings to Resident #2's toes per her request. The nurse (#11) stated, you must've been up a lot today your feet are more swollen. Observation showed no compression stockings or wraps on the resident's lower extremeties and the presence of [CONDITION(S)]. * 12/06/22 at 11:40 a.m., no compression stockings or wraps present on Resident #2's lower extremities. * 12/07/22 at 3:20 p.m., no compression stockings or wraps present on Resident # 2's lower extremities. Orders included: 08/15/22, TED stocking/ace wraps to bilateral lower extremities [BLE], on in am, off in pm every day and evening shift for [CONDITION(S)]. 11/16/22, Cover toenails with 4x4 [size of gauze dressings] gauze daily and clean sock. No hard toe shoes. One time a day for Ablation (medical procedure that removes a layer of tissue) of all 10 toenails until 11/30/2022. [Completed 11/30/22] The primary care provider note, dated 12/01/22 at 10:30 a.m., stated, . Chief complaint: Re-check bilateral feet. The patient had chemical removal of all 10 of her toenails by podiatry two weeks ago. We are doing regular dressing changes and is seen today just to recheck these feet. She does state some mild discomfort with dressing changes, otherwise no pain noted. We will continue the dressing changes as recommended per podiatry, otherwise will continue to follow for regular scheduled rounds and sooner if any problems arise. Resident #2's treatment administration record (TAR) showed staff applied the TED hose on December 5, however, observation showed no TED hose in place. On December 6 and 7, facility staff documented a 9 on the TAR indicating other and to refer to the progress notes. The record lacked documentation in the progress notes. Review of Resident #2's medical record lacked weekly wound assessments as per policy. The record also lacked documentation for not applying the compression stockings or wraps. During an interview on 12/08/22 at 01:05 p.m., two administrative staff (#1 and #2) stated they expected staff to document wound assessments in the progress notes. They also stated that if staff document a 9 in the TAR, they expected staff to document the reason in a progress note.