Based on observation, review of facility policy, record review and staff interview, the facility failed to use an assistive device necessary to prevent accidents for 1 of 5 sampled resident (Resident #185) observed during gait belt transfers. Failure to use a gait belt during a transfer resulted in pain to Resident #185 and may result in falls and/or injuries. Findings include: Review of the facility policy titled Gait Belts occurred on 01/04/23. This policy, dated October 2021, stated, . PURPOSE: To prevent injury to the resident . Gaitbelts [sic] are used . when nursing deems necessary. Review of Resident #185's medical record occurred on all days of survey. Diagnoses included repeated falls, pain and mild cognitive impairment. A physical therapy note, dated 01/02/24 at 4:09 p.m., stated, . Transfer: Supine-sit transfers . Sit-stand with CGA {contact guard assist] today with use of gait belt. During an observation on 01/02/24 at 5:09 p.m. a certified nurse aide (CNA) (#2) assisted Resident #185 from a lying position in the bed to a sitting position by pulling on the resident's left arm. The resident grimaced in pain and placed his right hand on his left shoulder The CNA stated, Is that left shoulder still bothering you? Without using a gait belt the CNA pulled on the back of the resident's pants to assist him to a standing position and provided hands on assistance on the resident's waist/bottom as the ambulated using the front wheeled walker. Observation showed the resident was unsteady and shuffled his feet and the CNA stated, Whoa you're a little wobbly today. The CNA held under the resident's left arm while he fell backwards on to the toilet. The resident finished using the toilet and the CNA pulled under the resident's arm to lift him up from the toilet. As the resident was ambulating out of the bathroom, he stated he needed to use the bathroom again. The CNA pulled under the resident's left arm as the resident sat down on the toilet. The resident finished using the toilet and the CNA pulled under the resident's left arm to a standing position. The CNA placed her hands on the resident's waist/buttocks for assistance as he ambulated to the recliner. The CNA held onto the back of the resident's pants as she lowered him into the recliner. During an interview on 01/04/23 at 11:51 a.m., an administrative nurse (#3) confirmed facility staff should not be pulling on or under Resident #185's arms or on clothing and should use a gait belt.

Based on observation, facility policy review, and staff interview, the facility failed to ensure staff followed standard infection control practices for 2 of 3 sampled residents (Resident #13 and #15) observed during personal cares. Failure to follow infection control practices related to hand hygiene and glove use has the potential to spread infection within the facility. Findings include: Review of the facility policy titled:Hand Hygiene: Use of alcohol-based hand rub occurred on 01/04/24. This policy, revised October 2021, stated, . hand hygiene . before and after resident contact . assisting a resident with personal cares . after contact with resident's skin . bodily fluids or excretions . Review of the facility policy titled; Perineal Care occurred on 01/04/24. This policy, revised October 2021, stated, PURPOSE: To prevent infections . wash urethral area first and rectal last . remove your gloves . perform hand hygiene . may apply a barrier cream . apply gloves . apple barrier cream to gloves . remove gloves . perform hand hygiene . - Observation on 01/02/24 at 11:48 a.m. showed a certified nursing assistant (CNA) (#1) entered Resident #13's room and performed incontinent bowel movement cares, removed the contaminated gloves, and donned new gloves. The CNA (#1) failed to perform hand hygiene after removing the contaminated gloves and prior to donning new gloves and applying a protective barrier cream to the resident's bottom. The CNA (#1) removed the gloves, assisted the resident with the blankets and call light and left the room without performing hand hygiene. - Observation on 01/03/24 at 10:51 a.m. showed a CNA (#1) donned gloves and provided perineal care for Resident #15. The CNA cleansed the rectal area of stool using a wet wipe and without removing the soiled gloves, applied a protective barrier ointment to the resident's bottom. During an interview on 01/04/24 at 11:50 a.m., a supervisory nurse (#3) confirmed she expected staff to perform hand hygiene upon entering and exiting a resident's room and in between glove changes.

Based on observation, review of facility policy, and staff interview, the facility failed to prepare, store, and serve food in a sanitary manner in 1 of 1 kitchen. Failure to monitor the quaternary (quat) sanitizer concentration may result in unsafe food storage/preparation and foodborne illness. Findings include: Review of the facility policy titled Kitchen/Table Pail occurred on 01/04/24. This policy, dated 01/03/24, stated, The kitchen pail is to be used for wiping down hard surfaces in the designated kitchen area. This pail will use our Sani-T-10 [quat] solution from dispenser on wall . is changed out to be tested with QUAC [quat] test strips three times a day per schedule and recorded and whenever changed out. The PPMs for the pail should read 150-400. If sanitizer levels are not within correct range, notify dietary manager. Observation on 01/03/24 at 8:50 a.m. showed a dietary staff member (#5) filled a pail with Sani-T-10 plus solution and water. The staff member failed to test the mixture with a QUAC test strip and stated he did not routinely do so. A second dietary staff member (#6) tested the mixture with a QUAC test strip and the strip failed to register a concentration. The dietary staff member (#6) discarded the mixture and prepared a new kitchen pail. Test of the second mixture with the QUAC strip showed a concentration of 200 ppm. During an interview with staff members (#5 and #6) after the above observation, they confirmed kitchen staff do not routinely test or log the sanitizer concentration of the mixture and failed to provide a log of sanitizer testing. During an interview on 01/03/24 at 9:15 a.m., the dietary manager (#7) confirmed she expected staff to test the kitchen pails per policy and log the results.

Based on record review, review of facility policy, review of resident rights guide, and resident and staff interviews, the facility failed to provide care in a manner and environment that maintained or enhanced the resident's dignity for 1 of 12 sampled residents (Resident #6). Failure to allow Resident #6 the choice to use her own beverage does not respect her personal preference and violates her rights to a dignified existence. Findings include: Review of the policy titled, Resident Rights occurred on 01/26/23. This policy, dated October 2022, stated, . It is the policy of this facility to protect and promote the right of each resident . including the right to a dignified existence, self-determination . The North Dakota Long Term Care Ombudsman Program Resident's Rights Guide, dated 08/01/19, stated, . The facility staff must treat you courteously, fairly and with dignity. Review of Resident #6's medical record occurred on all days of survey. The current care plan stated, . Allow resident to make choices . Respect her choices and resident rights. Progress notes included the following: * 01/15/23 at 3:10 p.m., . Behavior Note . [Resident #6] was in the dining room now at snack time and nurse went up behind her and informed her that I would have to ask her to leave the dining room as she has her pop cup on her chair which she was [sic] been informed is a [sic] infection control issue . * 01/15/23 at 11:44 p.m., . Behavior Note . [Resident #6] came from her room and she did not leave her pop cup in her room she put it on a table in the activity room. [Resident #6] has been instructed numerous times by multiple staff that this is an infection control issue, pop cup taken to her room. * 12/19/22 at 1:05 p.m., . Behavior Note Res. [Resident] brought her pop into the dining room at dinner. Res. has been talked to numerous times about this. Reminded res. that she can not have her pop in the dining room and that she needed to return it to her room. Res stated 'I'll just throw it away'. Resident threw pop away and returned to meal. * 12/15/22 at 1:35 p.m., . Behavior Note . Res did not have her oxygen tank filled prior to staff getting her up for Bingo, but she refused to stay in her room and wait on her concentrator before getting to activity room even though Bingo doesn't start until 1345 [1:45 p.m.]. Res then brings a can of diet coke to the activity room and cracks it open, sets it on the table, and when activity staff tells her that she can't have it in the activity room she gets verbally rude and upset with activity aide, 'well why can the activity staff have theirs in here then?' . * 12/3/22 at 3:00 p.m., . Behavior Note . [Resident #6] waiting in dining room for snack & asks multiple staff for 3 cups of ice for her water bottle. Nurse comes to dining room and sees [Resident #6] has her water bottle with her, which she knows she shouldn't have & has been reminded of multiple times. [Resident #6] getsupset [sic] when told to leave dining room and go put water bottle back in her room. [Resident #6] then finds out that the ice machine is currently out of ice at this current moment, and she will have to wait a few moments for it to produce more ice. She has a panic attack, freaking out on all staff members accusing them of doing everything wrong, breaking the machine, filling ice waters for residents incorrectly, and continuously accusing CNAs [certified nurses' assistant] of being in the wrong. Meanwhile, res still won't leave the DR [dining room] with her water bottle so had to be reminded again. Observation on 01/25/23 at 1:49 p.m., showed a twenty ounce bottle of pop on a table with four unidentified residents and one unidentified staff member during bingo in the activity room. During an interview on 01/24/23 at 4:40 p.m., when asked she feels about not being allowed to have her persona beverage container in the dining room/activity room, Resident #6 stated as far as she knows she is allowed to have it in the activity room but not the dining room. The resident stated she feels like she's a child when staff tell her she has to leave the dining room because she has her personal pop container in her chair and that it upsets her. During an interview on 01/25/23 at 3:15 p.m., when asked why Resident #6 was not allowed to bring her personal beverage container and/or bottle of pop in the dining room, a dietary staff member (#6) stated she had been told this by a previous dietary staff member. During an interview on 01/25/23 at 3:17 p.m., an administrative staff member (#2) stated Resident #6 is not allowed to bring her personal beverage container and/or bottle of pop to the dining room because it is brought from her room, it is an infection control issue because she touches her cup and it is dirty. The administrative nurse (#2) also stated the resident can have her personal beverage container and/or twenty ounce bottle of pop in the activity room. During an interview on 01/25/23 at 3:31 p.m., two administrative staff members (#1 and #5) stated Resident #6 is not allowed to have her personal beverage container or bottle of pop in the dining room or activity room whether it is on the table or in the holder attached to her wheelchair. An administrative staff member (#5) stated, We started this during Covid due to infection control, no residents are allowed to bring personal items into the dining room. The facility failed to honor the resident's right allowing her to have her personal beverage container and/or bottle of pop in the activity room/dining room and failed to treat the resident with dignity and respect her individual preferences.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide adequate supervision necessary to prevent accidents for 1 of 8 sampled residents (Resident #16) who required staff assistance for transfers. Failure to stay with the resident in the bathroom as care planned places the resident at risk for falls and/or injuries. Findings include: Review of the facility policy titled Care Plans - Baseline and Comprehensive Person-Centerted [sic] occurred on 01/26/23. This policy, revised October 2022, stated, . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . to meet a resident's medical, nursing, and mental and psychosocial needs . Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Review of Resident #16's medical record occurred on all days of survey and included diagnoses of unspecified dementia, fracture of unspecified part of neck of femur and history of falling. The current care plan stated, . TOILET USE: The resident requires one assist with toileting. FALLS . Do not leave me unattended while toileting as I am a high fall risk. Review of Resident #16's medical record occurred on all days of survey. A progress note dated 07/13/2022 at 12:56 p.m., stated, . Resident yelling for help, CNA [certified nursing assistant] found him on the floor in his bathroom in his room. Laying on his right side . He was on the toilet and fell when getting off . During an observation on 01/24/23 at 10:31 a.m., a CNA (#3) assisted Resident #16 from the wheelchair to the toilet using a gait belt. The CNA showed the resident where the call light was located. The CNA stated that the resident sits on the toilet for about 20 minutes. The CNA closed the bathroom door and walked out of the resident's room into the hallway. At 10:37 a.m., the CNA checked on the resident and at 10:44 a.m., the CNA assisted the resident off the toilet. During an interview on 01/25/23 at 2:51 p.m., an administrative nurse (#1) stated, I would expect staff to stay within eyesight of the resident.

Based on observation and staff interview, the facility failed to ensure safe and secure storage of medications in 2 of 2 medication carts (nurses medication cart and medication assistant's cart). Failure to store all medications securely may result in unauthorized access to medications. Findings include: - Observation on 01/25/23 at 11:27 a.m. showed a registered nurse (RN) (#4) removed four insulin pens from a drawer in the medication cart and placed them on top of the cart. The nurse pushed the medication cart down the hallway to the consultation room and stated, I'll be right back. The nurse returned to the medication cart at 11:32 a.m. Several residents were lined up in the hallway directly across from the medication cart waiting for access to the dining room for lunch. The nurse (#4) failed to securely lock the insulin pens in the medication cart in her absence. - Observation on 01/26/23 at 10:36 a.m. showed a unattended medication cart located on the C wing with an inhaler and a bottle of eye drops on top of the cart. During an interview on 01/26/23 at 10:31 a.m., an administrative nurse (#1) stated she expected staff to keep all medications locked securely in the medication cart when unattended.