Marian Manor Healthcare Center

Inspectors wrote1. Based on observation, record review, review of the facility investigation, review of facility policy, review of professional reference, and resident, resident representative, and staff interviews, the facility failed to provide appropriate supervision for 1 of 1 sampled resident (Resident #3) who experienced a choking episode. Failure of staff to remove snack items not on Resident #3's ordered diet from the resident's room and ensure all foods served follow the resident's mechanically altered diet order resulted in Resident #3 experiencing a choking episode and hospitalization and placed all residents on mechanically altered diets at risk for injury. During the standard survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 02/17/26 at 11:30 a.m. [...]

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to ensure proper labeling and storage of medications for 2 of 9 observations of medication preparation and administration. Failure to date an insulin pen with the open and discard date and failure to ensure medications are administered promptly after preparation may result in an ineffective dose of insulin and medication errors.

Inspectors wroteBased on survey findings, review of facility policy, professional reference, and staff interview, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to develop a Performance Improvement Project (PIP) to decrease or prevent the likelihood of problems or occurrences of adverse events, and ensure compliance with federal requirements related to a resident choking incident.

Inspectors wrote1. Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide adequate supervision for 2 of 3 sampled residents (Resident #38 and #204) with orders for electric heating pad use. Failure to provide adequate supervision during heating pad use resulted in a burn for Resident #38 and placed Resident #204 and all other residents who use heating pads at risk for burns. During the on-site recertification survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 02/07/24. The IJ was identified when a physician's order in Resident #38's medical record, dated 02/08/24, included a treatment for and a diagnosis of a first degree burn to the resident's right hip from an electric heating pad. [...]

Inspectors wroteBased on review of the Electronic Staffing Data Submission Payroll-Based Journal (PBJ) Long-Term Care Facility Policy Manual and staff interview the facility failed to submit direct care staffing information based on payroll data to the Electronic Staffing Data Submission PBJ for 1 of 4 reporting periods (Quarter #4). Failure to submit direct care staffing information may result in inaccurate representation of the level of staff in the facility which can impact the quality of care delivered.

Inspectors wroteBased on record review, review of facility policy, review of the facility investigation report, and staff interview, the facility failed to report an incident of potential neglect to the State Survey Agency (SSA) for 1 of 1 sampled resident (Resident #38) who experienced a burn from an electric heating pad. Failure to report an event of potential neglect to the SSA in the required time frame placed Resident #38 and other residents at risk for burns.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure the resident or their representative chose to accept or decline a bed hold for 2 of 3 sampled residents (Resident #38 and #46) reviewed for hospitalizations. Failure to obtain a resident or their representative's bed hold choice does not allow the resident and/or their representative to make an informed decision regarding their rights.

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 12 sampled residents (Resident #30). 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.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 3 of 12 sampled residents (Resident #21, #22, and #38). Failure to update care plans limited the staffs' ability to communicate needs and ensure continuity of care.

Inspectors wroteBased 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 discard outdated food items and monitor the sanitizer concentration may result in unsafe food storage/preparation and foodborne illness.

Inspectors wroteBased on observation, review of the North Dakota Plumbing Code, and staff interview, the facility failed to provide an air gap for 1 of 1 two-compartment sink observed in the main kitchen. Failure to provide the required air gap for a two-compartment sink has the potential to allow contamination of the sink in the event of a sewer back up.

Inspectors wroteBased on record review and staff interview, the facility failed to provide the resident or the resident's representative a written notice of transfer for 1of 1 resident (Resident #22) reviewed for hospital transfer. Failure to provide a written copy of the transfer notice does not allow the resident and/or their representative to make an informed decision regarding their rights.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to provide the resident or resident's representative a written bed hold notice for 1 of 1 resident (Resident #22) reviewed for hospital transfer. Failure to provide a written copy of the bed hold notice and include the reserve bed amount does not allow the resident and/or their representative to make an informed decision regarding their rights.

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 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 7 residents (Resident #4 and #31) prescribed Aspirin. Failure to accurately complete the MDS for medications taken by the residents may affect the accurate development of a comprehensive care plan and the care provided to the residents.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to ensure posting of accurate and complete staffing information on 3 of 4 days of survey (January 22-24, 2024). Failure to post accurate staffing data does not allow residents and visitors to be aware of the number of licensed and unlicensed staff on duty each shift.