Mountrail Bethel Home

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wrote1. 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteTHIS 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteTHIS 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to provide appropriate care and services for 2 of 4 sampled residents (Resident #16 and #24) who had a pressure ulcer. Failure to obtain and implement orders for treatment may result in the worsening of the pressure ulcer.

Inspectors wroteBased on information provided by complainants, observation, record review, review of facility policy, and staff interview, the facility failed to provide appropriate services and assistance to maintain bowel /bladder continence for 1 supplemental resident (#17) observed. Failure to provide toileting assistance may result in unnecessary incontinence and a loss of dignity.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to maintain acceptable parameters of nutritional status or 1 of 1 sampled resident (Resident #14) with significant weight loss. Failure to reassess/monitor weight variances may delay needed treatment for weight loss and alter the resident's ability to maintain sufficient nutritional status.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a rationale and duration for the use of an as needed (PRN) psychotropic medication for 1 of 1 sampled resident(Resident #9) with a PRN psychotropic. Failure to ensure a rationale and duration of a PRN medication places the resident at risk for receiving unnecessary medications and experiencing adverse consequences related to their use.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to ensure safe and secure storage of medications for 1 of 2 medication carts (south cart) observed unlocked or with unattended medications. Failure to store all medications securely may result in unauthorized access to medications.

Inspectors wroteBased on review of Medicare Part A letters/notices and staff interview, the facility failed to complete the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) and ensure the Notice of Medicare Non-Coverage (NOMNC) contained updated contact information for the Quality Improvement Organization (QIO) for 1 of 1 supplemental resident (Resident #27) who remained in the facility and 1 discharged resident (Resident #37). Failure to ensure the resident and/or resident representative received all available options for care and the option to appeal the termination of coverage has the potential to hinder the residents' right to an expedited review of a service termination.