Based on record review and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 2 of 13 sampled residents (Resident #33 and #39). Failure to update care plans limited the staffs' ability to communicate needs and ensure continuity of care. Findings include: - Review of Resident #33's medical record occurred on all days of survey. A physician's order, dated 07/16/24, stated, Hiprex [antibiotic/antibacterial medication] Oral Tablet 1 GM [gram] . Give 1 tablet by mouth two times a day for prevent uti [urinary tract infection]. The current care plan stated, . Monitor/document for s/s [sign/symptoms of] UTI . The facility failed to update Resident #33 care plan to include a medication to prevent UTIs. - Review of Resident #39's medical record occurred on all days of survey. A physician's order, dated 09/23/24, stated, Hiprex Oral Tablet 1 GM . Give 1 tablet by mouth two times a day for Recurrent [sic] UTIs. The current care plan stated, . Monitor/document for s/s UTI . The facility failed to update Resident #39's care plan to include a medication for recurring UTIs. During an interview on 01/30/25 at 12:19 p.m., an administrative nurse (#1) confirmed staff failed to revise Resident #33 and Resident #39's care plans.

Based on observation, review of facility policy, review of manufacturer's instructions, and staff interview, the facility failed to ensure staff followed standards of practice for 1 of 2 residents (Resident #33) observed for insulin preparation and administration. Failure to properly prime an insulin pen and administer insulin correctly may result in residents receiving an inaccurate dose of insulin. Findings include: Review of the facility policy titled Insulin Administration, Insulin Pens, Insulin Pumps occurred on 01/30/25. This policy, revised 09/05/24, stated, . Insulin Pen. Turn the dosage knob to '2' units to prime the pen. 10.) Holding the pen with the needle pointing upwards, press the button until at least a drop of insulin appears. 11.) Dial in the ordered dose of units. Inject the dose into the chosen site. Be sure to wait 6 seconds to ensure that the full dose has been delivered. Review of manufacturer's Instructions For Use of Lantus occurred on 01/30/25 and stated, . Injecting your Lantus Dose: Place your thumb on the injection button. Then press all the way in and hold. Keep the injection button held in and when you see '0' in the dose window, slowly count to 10. This will make sure you get your full dose. After holding and slowly counting to 10, release the injection button. Observation on 01/29/25 at 11:30 a.m. showed a staff nurse (#9) prepared Resident #33's Lantus insulin pen for administration. The nurse (#9) primed the insulin pen holding the pen down towards the garbage can. The nurse (#9) administered the insulin and immediately removed the needle from the resident's skin. The nurse failed to hold the pen upward when priming, hold the injection button in and count to 10. During an interview on 01/30/25 at 12:24 p.m., an administrative nurse (#1) stated she expected staff to prime an insulin pen with the needle upright and to hold the needle into the skin per policy/instructions.

Based on observation, review of manufacturer's instructions and staff interview, the facility failed to sanitize surfaces in 1 of 1 facility kitchen. Failure to ensure the concentration of quaternary (quat) sanitizing solution is within manufacturer's guidelines may result in an incorrect solution concentration. Inadequate sanitization of the kitchen surfaces places residents at risk for foodborne illness. Findings include: Review of the manufacturer's instructions for Ecolab's Oasis 146 Multi-Quat Sanitizer occurred on 01/29/25. This information identified a concentration of 150- 400 ppm (parts per million) for effective sanitizing. Observation during the initial kitchen tour on 01/27/25 at 10 a.m., showed a dietary staff member (#11) wiped a food-prep counter in the kitchen with a cloth from a bucket of solution. The dietary staff (#10) identified the solution in the bucket as the quat disinfecting solution she obtained from the main kitchen earlier that morning. Upon request, the dietary staff member (#10) tested the solution twice using expired Hydrion QT 40 test strips. The results measured 50-100 ppm, below the 150-400 ppm manufacturer's recommendation. Observation in the kitchen on 01/30/25 at 10:20 a.m., showed an administrative staff (#2) tested a bucket of pre-mixed quat solution prepared for disinfection of the kitchen counters. The quat solution tested below 100 ppm, and staff discarded it. Testing of a second bucket of pre-mixed quat solution showed 100 ppm and staff discarded it. During an interview on 01/30/25 at 10:30 a.m., an administrative staff (#2) stated staff are expected to test quat solution with up to date test strips and assure the solution is mixed to the correct concentration.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 5 of 13 sampled residents (Resident #20, #30, #36, #38 and #200) and one supplemental resident (Resident #2) observed during cares and medication pass. Failure to practice infection control standards related to enhanced barrier precautions (EBP), droplet precautions, and hand hygiene, has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 01/28/25. This policy, revised on 03/29/22, stated, . Policy: . All employees in patient cares areas . will adhere to . Hand Hygiene . 3 After bodily Fluid/Glove Removal . according to standard precautions . 2. Hand hygiene should be performed after glove removal . Procedure: HCW [Health Care Workers] will use waterless alcohol-based hand sanitizer or soap and water to clean their hands: . After removing gloves regardless of task completed . After contact with a patient's excretions . When moving from contaminated body site to clean body site during patient care . Review of the facility policy titled Standard and Transmission-Based Precautions occurred on 01/28/25. This policy, reviewed/revised on 04/02/2024, stated, . Standard precautions apply to . all body fluids . excretions . Standard precautions include handwashing, personal protective equipment, cleaning of resident care equipment . Enhanced Barrier Precautions . refer to the use of gown and gloves during high-contact resident care activities . Enhanced Barrier Precautions are needed for . Residents with Indwelling Medical Devices (. indwelling urinary catheters, feeding tubes .) . High-Contact Resident care Activities include: Transfers, dressing, assisting during bathing, providing hygiene, changing briefs . contact while assisting with transfers . Droplet Precautions will be used in addition to standard precautions for a resident/patient known or suspected to be infected with microorganism transmitted by droplet . clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE [personal protective equipment] . - Review of Resident #30's medical record occurred on all days of survey. The current care plan stated, . The resident needs Enhanced Barrier Precautions related to indwelling catheter and feeding tube. Observation on 01/27/25 at 9:43 a.m. showed an enhanced barrier precaution sign outside of Resident #30's room. A certified nurse aid (CNA) (#6) entered Resident #30's room without applying a gown to complete morning cares. With gloved hands, the CNA (#6) completed personal and catheter cares. Without removing the gloves and performing hand hygiene, the CNA performed perineal cares after a bowel movement. Without removing the soiled gloves or performing hand hygiene, the CNA (#6) continued with the rest of the morning cares, including placing clothing on the resident. - Review of Resident #200's medical record occurred on all days of survey. The current care plan stated, . The resident has an ADL [activities of daily living] self care performance deficit . check resident . for incontinence/toileting needs . Observation on 01/27/25 at 1:32 p.m. showed a CNA (#6) performed perineal cares for Resident #200 after a bowel movement. After completing cares, the CNA (#6) failed to remove his/her gloves, applied a new brief, pulled up the resident's pants, and adjusted the resident's shirt. The CNA then removed the soiled gloves and without performing hand hygiene, placed a blanket over the resident, placed the call light within reach of the resident, and opened the window blind. During an interview on 01/30/25 at 12:19 p.m., an administrative nurse (#1) confirmed she expected staff to remove gloves and perform hand hygiene after perineal cares, and for staff to follow the policy when providing high-contact cares for residents in enhanced barrier precautions. - Review of Resident #36's medical record occurred on all days of survey. The current care plan stated, . requires enhanced barrier precautions . monitor lung sounds . Observation on 01/27/25 at 2:43 p.m. showed a staff nurse (#4) entered Resident #36's room and assessed lung sounds with a stethoscope. After the assessment, the nurse placed the stethoscope around her neck, left the room, and walked down the hall. The nurse (#4) failed to disinfect the stethoscope. During an interview on 01/30/24 at 12:20 p.m., an administrative nurse (#1) stated she expected staff to sanitize medical equipment used for a resident on EBP. - Review of Resident #20's medical record occurred on all days of survey. The care plan stated, The resident needs Enhanced Barrier Precautions related to indwelling catheter. Observation on 01/28/25 at 8:43 a.m. showed a CNA (#7) transferred Resident #20 from the wheelchair to the recliner. The CNA (#7) stated, the resident is in EBP for his foley catheter and staff only need a gown when working with the catheter. The CNA (#7) failed to wear a gown when transferring Resident #20. During an interview on 01/30/25 at 12:14 p.m., an administrative nurse (#1) stated she expected staff to wear a gown for all transfers in EBP rooms. - Observation on 01/29/25 at 11:45 a.m., showed a Medication Aide (MA) (#8) administered eye drops to Resident #2. The MA (#8) applied gloves, administered the eye drops, removed the gloves, and left the room without performing hand hygiene. The MA returned to the medication cart and failed to perform hand hygiene. During an interview on 01/30/25 at 12:24 p.m., an administrative nurse (#1) stated she expected staff to perform hand hygiene after administering eye drops. - Review of Resident #38's medical record occurred on all days of survey. Diagnosis included influenza. Observation on 01/27/25 at 4:09 p.m., showed a droplet precautions sign outside of Resident #38's room. A CNA (#5) entered Resident #38's room and performed toileting and transferring cares. After cares, the CNA (#38) exited the room and failed to remove his mask. During an interview on 01/30/24 at 12:20 p.m., an administrative nurse (#1) stated she expected staff to remove PPE after cares in a droplet precautions room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 01/19/23 Based on 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 12 sampled residents (Resident #29 and #44) and one supplemental resident (Resident #12). 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: SECTION E: BEHAVIORS The Long-Term Care Facility RAI User's Manual, revised October 2023, page E-1, stated, Intent: The items in this section identify behavioral symptoms in the last seven days that may cause distress to the resident, or may be distressing or disruptive to facility residents, staff members or the care environment. These behaviors may place the resident at risk for injury, isolation, and inactivity and may also indicate unrecognized needs, preferences or illness. Page E-4 stated, . E0200C: Behavioral Symptom-Presence & Frequency. Note presence of symptoms and their frequency. C. Other behavioral symptoms not directed towards others (e.g., verbal/vocal symptoms like screaming, disruptive sounds) . Review of Resident #44's medical record occurred on all days of survey. Review of nursing progress notes from 10/19/23 through 10/25/23 (the 7-day look back period) showed the following: * 10/20/23 at 2:43 p.m., . shouting out most of the morning. * 10/22/23 at 5:51 a.m., . screamed intermittently between 0100 [1:00 a.m.] and 0200 [2:00 a.m.] and then between 040430 [sic] to 0510 [5:10 a.m.]. * 10/24/23 at 11:14 a.m., . shouting out loud repeatedly since he has been in his w/c [wheelchair]. * 10/25/23 at 7:32 p.m., . Yelling on and off during the shift, upset several residents at supper . The quarterly Minimum Data Set (MDS), dated [DATE], showed staff failed to code section E200 for behaviors for Resident #44. During an interview on 01/18/24 11:46 a.m., an administrative staff member (#2) confirmed staff failed to code Resident #44's MDS correctly. SECTION I: ACTIVE DIAGNOSES The Long-Term Care Facility RAI User's Manual, revised October 2023, page I-8, stated, . Code diseases that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period . Check off each active disease. Check all that apply. If a disease or condition is not specifically listed, enter the diagnosis and International Classification of Diseases [ICD] code in item I8000, Additional active diagnosis. Review of Resident #29's medical record occurred on all days of survey. The record showed ZyPREXA [an antipsychotic medication] . for paranoia . ordered on 11/22/23. The quarterly MDS, dated [DATE], showed staff failed to code Resident #29's diagnosis of paranoia. During an interview on 01/18/24 11:46 a.m., an administrative staff member (#2) confirmed the facility failed to code paranoia as an active diagnosis on Resident #29's MDS. SECTION N: MEDICATIONS The Long-Term Care Facility RAI User's Manual, revised October 2023, pages N-6 to N-8, stated, N0415: High-Risk Drug Classes . Coding Instructions: Code all high-risk medications according to their pharmacological classification, not how they are being used. N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g. clopidogrel) was taken by the resident at any time during the 7-day observation period . Review of Resident #12's medical record occurred on all days of survey. Physician's orders included clopidogrel, initiated on 01/31/23. The annual MDS, dated [DATE], showed staff failed to code Resident #12's use of an antiplatelet medication. During an interview on 01/18/24 at 10:58 a.m., an administrative staff member (#2) confirmed the facility failed to code clopidogrel on the MDS.

Based on record review, review of the North Dakota Provider Manual Preadmission Screening and Resident Review (PASARR) and Level of Care Screening Procedures for Long Term Care Services, and staff interview, the facility failed to complete a status change assessment for 1 of 2 sampled residents (Resident #29) reviewed for PASARR. Failure to complete a change in status assessment with a newly diagnosed mental illness may result in the delivery of care and services inconsistent with the resident's needs. Findings include: The North Dakota PASARR Provider Manual, revised 12/29/20, page 13 states, . Change in Status Process . Whenever the following events occur, nursing facility staff must contact Maximus to update the Level I screen for determination of whether a first time or updated Level II evaluation must be performed. These situations suggest that a significant change in status has occurred: . If an individual with MI, ID, and/or RC (mental illness, intellectual disability, and conditions related to intellectual disability [referred to in regulatory language as related conditions or RC]) was not identified at the Level I screen process, and that condition later emerged or was discovered. Review of Resident #29's medical record occurred on all days of survey and identified a Level I PASARR completed on 03/03/23. The record showed Resident #29 received a new diagnosis of paranoia on 11/22/23. The record lacked evidence the facility completed a change in status assessment with the new diagnosis. During an interview on 01/18/24 at 9:39 a.m., an administrative staff member (#2) confirmed the facility failed to submit another PASARR for Resident #29 following the new diagnosis.

Based on observation, record review, review of manufacturer's instructions, and staff interview, the facility failed to provide adequate supervision and assistive devices necessary to prevent accidents for 1 of 4 sampled residents (Resident #9) observed during a transfer utilizing a sit-to-stand mechanical lift transfer. Failure to ensure proper use of a stand lift during transfers placed the resident at risk for accidents and injury. Findings include: Review of the facility policy titled Safe Resident Handling, dated January 2023, stated, . enables caregivers to safely support residents who require partial or total assistance to ambulate, transfer and reposition . mobility equipment . refers to sit to stand lifts . slings a resident uses with mobility tasks . caregivers with perform am TIME OUT safety stop while the resident is in a sling or harness and still over the surface . to ensure all straps are secure before moving away from the surface . this is to be completed once the straps are taut, but before the resident leaves the surface . Review of Resident #9's medical record occurred on all days of survey. The current care plan stated to transfer . EZ stand lift with two assist and seat sling . Observation on 01/16/24 at 1:27 p.m. showed two certified nurse aides (CNAs) (#8 and #11) attached the harness, the shin strap of the sit-to-stand mechanical lift, the resident yelled, ouch, and, it hurts, and grimaced as the CNAs raised the lift. The harness straps pulled upward into Resident #9's armpits, her shoulders raised to her ear level and her elbows extended horizontally. The CNAs failed to apply the seat sling before they transferring Resident #9 from the wheelchair to the toilet. The CNA (#9) noticed the harness loosely positioned on the resident, and tightened the strap while the resident sat on the toilet. As the resident hung with the harness under her armpits, she stated, ouch and grimaced while the CNAs transferred her across the room to her recliner chair. One of the CNAs (#11) asked Resident #9 if she felt better after being lowered into her recliner, and Resident #9 responded Yes. During an interview on 01/16/24 at 4:40 p.m., an administrative nurse (#1) stated the CNAs are expected to provide safe transfers.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure the resident's medication regimen remained free of unnecessary medications for 1 of 3 sampled residents (Resident #44) reviewed for antipsychotic medications. Failure to consistently monitor residents while on the medication may result in the residents experiencing adverse consequences related to the antipsychotic medication. Findings include: Review of the facility policy titled Tardive Dyskinesia occurred on 01/18/24. This policy, reviewed 02/07/23, stated, . Tardive Dyskinesia (TD) is an involuntary movement disorder that may appear after use of neuroleptic medications [antipsychotics]. Upon initiation of antipsychotic medication therapy, a baseline assessment shall be completed . Positive screenings will be . considered in the continuation of drug therapy . The User-Defined Assessment (UDA) utilized by the facility for Abnormal Involuntary Movement Scale (AIMS) assessments, stated, . Abnormal Involuntary Movement Scale . Required at least every six months when resident is receiving an antipsychotic medication. Review of Resident #44's medical record occurred on all days of survey. Physician's orders included Risperdal (an antipsychotic) initiated on 07/29/22. The record identified the facility completed an AIMS on 04/24/23. During an interview on 01/18/24 at 11:46 a.m., an administrative staff member (#1) stated the facility completes AIMS assessments when an antipsychotic medication is started and every six months thereafter and confirmed the facility failed to complete an AIMS assessment for Resident #44 six months after April 2023.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure appropriate labeling of medications for 1 of 6 residents (Resident #45) observed during medication administration. Failure to ensure medication cards contain the correct administration information may result in medication errors and adverse drug effects. Findings include: Review of the facility policy titled Medications: Acquisition Receiving Dispensing and Storage occurred on 01/18/24. This policy, revised 02/02/23, stated, . Licensed nursing employees are responsible for ordering from pharmacy . and checking all new orders of medications from the physician's orders . The medication orders/changes are communicated to the pharmacy. All medications . are packaged in accordance with . state pharmacy rules. Observation on 01/17/24 at 9:46 a.m. showed a nurse (#5) administered Resident #45's medications. The pharmacy labels on the cards identified Lorazepam 0.5 mg [milligrams] 1 tablet BID [two times a day] and every 6 hours PRN [as needed] and Oxycodone 5 mg 1 tablet BID and every 6 hours PRN. Review of Resident #45's medical record identified the physician discontinued the PRN orders for Lorazepam and Oxycodone on 11/06/23. During an interview on 01/17/24 at 2:30 p.m., an administrative nurse (#1) confirmed she expected staff to communicate order changes to pharmacy and a new label to be affixed by pharmacy.

Based on observation, review of facility policy, and staff interview, the facility failed to maintain sanitary food service in 1 of 3 kitchenettes (Eagle Bend). Failure to ensure safe transportation of foods to resident rooms and ensure utilization of sanitary food service equipment has the potential to result in contamination of food and spread illness to resident, staff, and visitors. Findings Include: Review of the facility policy titled Safe Meal Service occurred on 01/18/24. This policy, reviewed 01/11/23, stated, . Meals served in resident's rooms . need to be covered during transportation. Upon completion of the meal by the resident in their room, nursing will document the necessary detail of food consumption before placing the used tray into the enclosed 'dirty' cart in the kitchenette. The Nutrition and Food Services employees will retrieve the tray to bring back to the dish room for processing. Observation on 01/18/24 at 8:47 a.m. showed a certified nurse aide (CNA) (#9) transported a meal tray to Resident #8's room. The tray contained three uncovered cups of liquids. The CNA arrived outside the resident's room, placed the tray on the hallway floor, donned the necessary personal protective equipment (PPE), and carried items from the food tray into the resident's room. The CNA (#9) then doffed the PPE, removed the serving tray from the hallway floor, and placed the tray in the middle of a stack of clean serving trays to be used to serve additional residents' meals. During interviews on 01/18/24 at 10:11 a.m. and 10:47 a.m., administrative staff members (#3 and #9) agreed staff should not place room trays containing food items on the floor, cover items delivered to residents, and place the dirty meal tray onto the dirty cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy, review of food temperature logs, review of resident council meeting minutes, and resident, family, and staff interviews, the facility failed to serve hot foods at palatable temperatures on 3 of 3 units (Pine Ride, [NAME] Hills, and Eagle Bend). Failure to serve foods at a temperature acceptable to residents may result in decreased intake, weight loss, and inadequate nutrition. Findings include: Review of the facility policy titled Food Temperature Monitoring - Food and Nutrition Services occurred on 01/18/24. This policy, revised 12/21/23, stated, . Proper holding temperature - Temperature required for food safety ( . hot food > [greater than] 135 degrees Fahrenheit) . Proper serving temperature - A temperature that is . appetizing to the resident . Food is cooked, reheated or cooled to ensure proper holding temperatures . Food temperatures are taken and recorded before each meal service. Periodically, temperatures are taken at other times during or at the end of meal service to ensure temperatures are held within acceptable ranges . hot foods should be served at 135 degrees Fahrenheit or higher. Interviews on the morning of 01/16/24 identified the following: * Resident A - The food is sometimes cold. I eat it anyway. * Resident B - Eats in her room. The food is sometimes cold, and she will not eat it if it's cold. * Family member AA - Feeds her family member and the food does not come very warm, the only thing hot is the soup. Review of resident council meeting minutes for September - December 2023 occurred on 01/16/24 and identified the following: * November 22, 2023 minutes stated, Food is sometimes cold by the time it is served to them. * December 27, 2023 minutes stated, Residents said the food is always cold when they receive it. During an interview on 01/16/23 at 10:20 a.m., a dietary manager (#3) reported staff take food temperatures in the main kitchen before taking food to kitchenettes for service, in the kitchenettes at beginning of service, in the middle of service, and at the end of the service. Review of temperature logs from November 1, 2023 to January 17, 2024 identified the following: * [NAME] Hills - 20 days with temperatures recorded below 135 degrees. * Pine Ridge - 2 days with temperatures recorded below 135 degrees. * Eagle Bend - 5 days with temperatures recorded below 135 degrees. Observation on 01/18/24 at 8:54 a.m. showed Resident #6 asked a staff nurse (#6) for a breakfast room tray. The nurse asked a dietary staff member (#7) to prepare a breakfast tray for the resident and to include French toast. Observation showed the breakfast foods on a rolling cart and not in the steam table. The dietary staff member (#7) placed two pieces of French toast on a plate, placed a cover over the plate, and handed the plate to the nurse (#6). The surveyor asked the dietary staff (#7) to obtain a temperature reading of the French toast. The thermometer read 126 degrees. Without reheating the French toast, the dietary staff member replaced the cover on the plate and handed it to the nurse (#6). The nurse then asked the dietary staff member what the temperature should be. The dietary staff (#7) member responded, Oh about 140 to 145 degrees. The nurse asked the dietary staff member to reheat the French toast. The dietary staff reheated the toast, the nurse asked for a temperature reading, and the temperature reading read under 140 degrees. The nurse again asked the dietary staff member to reheat the French toast with the last temperature reading 165 degrees. During an interview on 01/18/24 at 7:51 a.m., a dietary manager (#3) stated he expected staff to serve food at 135 degrees or above and monitor and maintain the food temperature for the entire service. During an interview on 01/18/24 at 10:47 a.m., a dietary manager (#3) confirmed dietary staff member (#7) failed to follow food safety requirements and stated if the French toast was not at the holding temp of 135 degrees, he would expect staff to reheat the French toast to 165 degrees before serving it to Resident #6.

Based on observation, review of facility policy, record review, and staff interview, the facility failed to ensure a safe, clean, comfortable, homelike environment for 1 of 1 sampled resident (Resident #46) with a personal fan. Failure to clean personal fans does not provide a comfortable/homelike environment and has the potential to place the resident at risk for injury or illness. Findings include: Review of the facility policy titled Cleaning of the Resident Personal Fans occurred on 01/19/23. This policy, dated 01/01/17, stated, PURPOSE: Process for ensuring residents personal fans are kept clean . PROCEDURE: 1. Family is to make facility aware . 2. Maintenance is to ensure the fan is in good working condition . Observation on 01/17/23 at 11:50 a.m., showed Resident #46 seated in the recliner chair with oxygen administered by nasal cannula. A small fan located on the overbed table blew air directly toward the resident. The outside fan cover/grate and fan blade contained visible dust. After an unidentified staff member transferred Resident #46 to the bed, the staff member placed the small fan on the overbed table next to the bed, the fan blew air directly toward the resident. Review of Resident #46's medical record occurred on all days of the survey. Diagnoses included acute and chronic respiratory failure with hypoxia, pneumonia, and chronic obstructive pulmonary disease. Resident #46's current care plan stated, . Resident currently utilizing oxygen continuously due to acute/chronic respiratory failure. During an interview on 01/19/23 at 11:00 a.m., an administrative staff member #1 stated his/her expectation is all staff should clean dirty equipment in resident's rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Review of Resident #28's medical record occurred on January 17-18, 2023. A medication order, dated 01/08/20, stated, Clopidogrel Bisulfate Tablet 75 MG, Give 75 mg by mouth one time a day for CVA. Resident #28's quarterly MDS, dated [DATE], identified an anticoagulant coded for seven days. The record failed to show an order for an anticoagulant. During an interview on 01/19/23 at 9:52 a.m., an administrative nurse (#2) confirmed she coded the MDSs incorrectly for the medication. SECTION P: RESTRAINTS AND ALARMS The Long-Term Care Facility RAI User's Manual, revised October 2019, page P-9 stated, P0200: Alarms . Coding instructions: Identify all alarms that were used at any time (day or night) during the 7-day look-back period. Code 0, not used: if the device was not used during the 7-day look-back period. Code 1, used less than daily: if the device was used less than daily. Code 2, used daily: if the device was used on a daily basis during the look-back period. Coding Tips, Bed alarm includes devices such as a sensor pad placed on the bed or a device that clips to the resident's clothing. Chair alarm includes devices such as a sensor pad placed on the chair or wheelchair or a device that clips to the resident's clothing. Observation on 01/17/23 at 1:00 p.m. showed Resident #26 used both a bed and a chair alarm. Review of Resident #26's medical record occurred on all days of survey. A progress note dated 10/05/22 at 11:20 a.m. stated, . bed alarm on and working properly. Facility staff completed a Physical Device and Restraint Assessment on 10/10/22 which identified the devices of silent alarm to bed and chair. The care plan identified the intervention Monitor [resident's name] every 30 minutes for fall, prevention, silent alarm to bed and chair dated 10/10/22. Review of the quarterly MDS, dated [DATE], identified the facility coded sections P0200 A. Bed Alarm and B. Chair alarm, as 0 not used. During interviews on the morning of 01/19/23, the administrative staff (#1 and #2) confirmed the staff failed to code Resident #26's MDS for a bed and chair alarm. - Review of Resident #7's medical record occurred on January 17-18, 2023. A medication order, dated 01/14/21, stated, Clopidogrel Bisulfate Tablet 75 MG, Give 75 mg by mouth in the morning related to atherosclerosis [narrowing of arteries caused by buildup of plaque] . The quarterly MDS, dated [DATE], identified an anticoagulant coded for seven days. The record failed to show an order for an anticoagulant. Based on observation, record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 14 sampled residents (Resident #26 and #28) and one supplemental resident (Resident #7). 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: SECTION N: MEDICATIONS The Long-Term Care Facility RAI User's Manual, revised October 2019, page N-6 and N7 stated, . Coding Instructions N0410A-H: Code medications according to the pharmacological classification, not how they are being used. N0410E, Anticoagulant [blood thinner] . Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel here. - Review of Resident #26's medical record occurred on all days of survey. A medication order, dated 04/21/21, stated, Clopidogrel Bisulfate [Plavix, a platelet aggregation inhibitor] Tablet 75 mg [milligrams] by mouth one time a day for acute CVA [cerebral vascular accident] The quarterly MDS, dated [DATE], identified an anticoagulant medication coded for seven days. The record failed to show an order for an anticoagulant.

Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure staff followed standards of practice for 1 of 1 resident (Resident #23) observed during administration of short acting insulin. Failure to administer rapid-acting insulin within five to ten minutes of a meal may result in a hypoglycemic (low blood sugar) reaction. Findings include: Review of the facility policy titled MEDICATION ADMINISTRATION occurred on 01/18/23. This policy, dated April 2022, stated, PURPOSE: . To provide safe administration of medication to residents by a nurse or CMA [certified medication aide] . PROCEDURES: 1. Follow the '6 rights' in medication administration at all times. a. Right resident b. Right medication . e. Right time . Review of the facility guideline regarding Humalog insulin by the Therapeutic Research Center, dated September 2021, stated, . Humalog is rapid acting human insulin analog indicated to improve glycemic control in adults and children with diabetes mellitus . usual frequency . Inject subcutaneously within five to ten minutes before a meal . Review of Resident #23's medical record occurred on all days of survey. Diagnoses included diabetes mellitus. Observation on 01/17/23 at 11:10 a.m., showed a nurse (#6) administered five units of Humalog insulin to Resident #23 per physician's orders. The nurse left the room and failed to offer any drink or food. At 11:28 a.m., an unidentified staff member brought the resident to the dining room. Resident #23 received the meal tray at 11:43 a.m., 33 minutes after receiving Humalog Insulin. During an interview on 01/19/23 at 10:00 a.m., an administrative staff member (#5) confirmed rapid-acting insulin should be injected within five to ten minutes before a meal.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide adequate assistance for 1 of 4 sampled residents (Resident #42) who required assistance for repositioning. Failure to ensure the correct technique in repositioning puts the resident at risk for pain and/or injury. Findings include: Observation on 01/17/23 at 12:54 p.m., showed two certified nurse aides (CNAs) (#3 and #4) assisted Resident #42 with repositioning in a recliner. The CNAs reached under the resident arms, grabbed the back of his pants, and lifted the resident further back into the recliner. Review of the facility policy/procedure titled Gait-Transfer Belt - LTC [Long Term Care] occurred on 01/19/22. This policy, dated 05/03/22, stated,. Do not use the pants/slacks belt as a gait (transfer) belt. Upward movement of the belt can cause male residents severe pain. During an interview on 01/19/23 at 9:22 a.m., administrative staff (#1 and #5) stated they expect staff not to lift under the arms and use the back of the pants to lift/reposition a resident.

Based on observation, review of facility policy, and staff interview, the facility failed to accurately label multi-dose insulin pens for 1 of 1 resident (Resident #23). Failure to label multi-dose insulin pens with the date opened increases the risk of residents receiving outdated medications with reduced medication efficacy. Findings include: Review of the facility policy titled Medication Administration, Insulin Administration occurred on 01/18/23. This policy dated August 2022, stated, . For medication designed for multiple administrations (e.g., insulin), the employee opening the mediation writes the open date on the label to promote correct administration . check label on vial carefully to ensure correct date vial was opened . Observations on 01/17/23 of insulin pens showed the following: * 11:10 a.m., a staff nurse (#6) administered Humalog insulin to Resident #23. The insulin pen failed to contain an open date. During the observation, the nurse (#6) confirmed the pen lacked an open date and stated the insulin pen should be dated. * 11:12 a.m., showed Resident #23's Lantus Insulin pen, located in the mediation cart, lacked a date when opened. During an interview on 01/19/23 at 10:00 a.m., an administrative nurse (#5) confirmed staff failed to date the insulin pens when opened.

Based on observation, review of the North Dakota Plumbing Code, and staff interview, the facility failed to provide an air gap for 1 of 4 ice machines (main kitchen) observed. Failure to provide the required air gap for the ice machine has the potential to allow contamination of these machines in the event of a sewer back up. Findings include: Review of the 2018 North Dakota Plumbing Code, Section 801.2 Air Gap or Air Break Required, stated, Indirect waste piping shall discharge into the building drainage system through an air gap or air break as set forth in this code. Where a drainage air gap is required by this code, the minimum vertical distance as measured from the lowest point of the indirect waste pipe or the fixture outlet to the flood-level rim of the receptor shall be not less than 1 inch (25.4 mm). Section 801.3.3 Food-Handling Fixtures, stated, Food-preparation sinks, steam kettles, potato peelers, ice cream dipper wells, and similar equipment shall be indirectly connected to the drainage system by means of an air gap. Bins, sinks, and other equipment having drainage connections and used for the storage of unpackaged ice used for human ingestion, or used in direct contact with ready-to-eat food, shall be indirectly connected to the drainage system by means of an air gap. Each indirect waste pipe from food-handling fixtures or equipment shall be separately piped to the indirect waste receptor and shall not combine with other indirect waste pipes. The piping from the equipment to the receptor shall be not less than the drain on the unit and in no case less than 1/2 of an inch (15 mm). Observations on 01/17/23 at 10:45 a.m. and on 01/19/23 at 9:40 a.m. showed the following in the main kitchen: * The end of the ice machine drainpipes laying directly on the grate of the floor drain. During an interview on 01/19/22 at 10:45 a.m., an administrative staff member (#1) confirmed the ice machine failed to have an air gap.