Rolette Community Care Center

Inspectors wroteBased on observation and staff interview, the facility failed to monitor hot water temperatures in resident rooms for 1 of 3 wings (wing 200) with elevated water temperatures. Failure to monitor hot water temperatures in resident rooms may result in resident pain, serious harm, serious impairment, or death. During the on-site recertification survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 09/29/25. The IJ was identified when facility water temperatures were taken in resident rooms on the 200 wing. Two of the resident rooms (room [ROOM NUMBER] and 208) registered a temperature of 137 and 133 degrees Fahrenheit (F). This finding placed all resident in immediate jeopardy for hot water burns. * 09/29/25 at 7:48 p.m. [...]

Inspectors wroteBased on observation, review of professional reference, review of facility policy, review of refrigerator temperature logs, and staff interviews, the facility failed to maintain cold storage areas and kitchen equipment in a sanitary manner for 1 of 1 kitchen. Failure to clean fans, shelving, and bulk bins in areas where food is stored, failure to ensure proper concentration of sanitizer solution, failure to discard outdated foods, failure to monitor refrigerator temperatures daily, and ensure refrigerator temperatures are within acceptable ranges has the potential for contamination of food and may result in a foodborne illness.

Inspectors wroteBased on staff interviews and review of facility job description the facility administrator failed to report to and remain accountable to the governing body. Failure to develop a process and frequency by which the administrator reports to and communicates with the governing body may result in a lack of information necessary for management of the facility.

Inspectors wroteBased on review of the Quality Assurance and Performance Improvement (QAPI) Team Member Attendance Forms and staff interviews, the facility failed to ensure required members of the QAPI Committee, attended 4 of 4 quarterly meetings (October 2024, 01/23/25, 04/24/25, and 07/24/25). Failure to have all required QAPI committee members attend and participate at QAPI meetings deprives the committee of each member's unique contribution for analysis of quality concerns and assisting with decision making based on identified concerns.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to complete a self-administration of medication (SAM) assessment for 1 of 1 sampled resident (Resident #4) observed with medications at the bedside. Failure to determine a resident's capacity to safely self-administer medications may result in medication errors, adverse drug events, and/or harm to the resident.

Inspectors wroteBased on observation and staff interview, the facility failed to promote privacy and confidentiality of the medication administration records for 1 of 2 days of survey. Failure to lock the electronic medication administration record (eMAR) may result in unauthorized viewing of confidential resident records by other residents, unlicensed staff, and visitors.

Inspectors wrote1. Based on record review, review of facility policy, and staff interview, the facility failed to ensure staff followed professional standards of practice for 2 of 12 sampled residents (Resident #12 and #14) reviewed for blood sugars and weights. Failure to follow physician's orders for out-of-range blood sugars and weight changes may result in adverse health events.2. Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure staff followed professional standards of practice for 1 of 1 supplemental resident (Resident #3) observed for medications administration via enteral tube. Failure to properly administer medications via feeding tube may result in adverse health events and/or a clogged tube.

Inspectors wroteBased on observation, record review, and resident interview, the facility failed to ensure 1 of 1 sampled resident (Resident #15) with contractures received the necessary hand devices. Failure to consistently place a carrot hand device or small towel roll to the resident's left hand may result in worsening of the contracture, pain, and skin breakdown. Findings Include:Review of Resident #15's medical record occurred on all days of survey. The care plan stated, The resident has hemiplegia [weakness or paralysis] of the L [left] UE [left upper extremity] . to maintain/improve UE ROM [range of motion] to prevent contractures. Recommend for the resident to use a carrot hand positioner or small towel roll for left hand. [...]

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to ensure safe and secure storage of medications, discard expired medications and label medications for 1 of 2 medication carts. Failure to securely store, label and discard expired medications may result in unauthorized access to medications, or residents receiving expired or incorrect medications.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to ensure residents received food served in the appropriate consistency for 1 of 2 sampled residents (Resident #13) with an altered diet. Failure to serve liquids according to the physician's diet order may place residents at risk of inadequate nutrition, unplanned weight loss/gain, choking, aspiration, aspiration pneumonia, and worsening of medical conditions.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 12 sampled residents (Resident #22) and one supplemental resident (Resident #3) observed during cares. Failure to practice infection control standards related to hand hygiene and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility.

Inspectors wroteBased on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to follow standards of infection control for 3 of 12 sampled residents (Resident #1, #3, and #10) and 1 supplemental resident (Resident #14) observed during cares. Failure to follow infection control practices related to enhanced barrier precautions (Resident #1 and #10) and transmission-based precautions (Resident #3 and #14) has the potential to spread infection throughout the facility. During the on-site recertification survey, the team determined an Immediate Jeopardy (IJ) situation existed on 09/09/24 at 1:32 p.m. [...]

Inspectors wroteBased on staff interview, the facility failed to ensure 1 of 1 dietary manager (#4) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure staff have the qualifications to carry out the functions of food and nutrition services has the potential to result in foodborne illness to residents, staff, and visitors.

Inspectors wroteBased on record review, staff interview, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, and review of the federal database for Long-Term Care Survey, the facility failed to ensure timely electronic data submission of required Minimum Data Set (MDS) assessments for 3 of 12 sampled residents (Resident #4, #5, and #20) and one supplemental resident (Resident #75). Failure to follow the MDS data submission specifications does not meet the intended regulatory requirements.

Inspectors wroteBased 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 5 of 12 sampled residents (Resident #1, #13, #16, #18, and #20). 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 the comprehensive care plan to reflect the current status for 7 of 12 sampled residents (Resident #1, #5, #7, #9, #10, #18, and #20). Failure to review and revise the care plan limited staff's ability to communicate needs and ensure continuity of care.

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 1 of 2 sampled residents (Resident #13) transferred to the hospital. 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 wrote1. Based on observation, review of professional reference, and staff interview, the facility failed to follow professional standards of practice for 1 of 1 sampled resident (Resident #10) observed for insulin preparation. Failure to prime an insulin pen correctly may result in residents receiving an inaccurate dose.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from unnecessary psychotropic medications for 2 of 4 sampled residents (Resident #5 and #11) reviewed for psychotropic medication use. Failure to limit as needed (PRN) psychotropic medication use to 14 days unless reevaluated by a practitioner, and failure to monitor the residents on psychotropics placed the residents at risk of receiving unnecessary medications and experiencing adverse drug effects and 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 2 of 2 unlocked and unattended carts (medication and treatment carts). Failure to securely store medications may result in unauthorized access to medications.

Inspectors wroteTHIS IS A REPEAT DEFICIENCY FROM THE PREVIOUS STANDARD SURVEY CONDUCTED ON 06/09/22. Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise comprehensive care plans to reflect the current status for 4 of 13 sampled residents (Resident #12, #17, #19, and #20) and 1 closed record reviewed (Resident #22). Failure to review and revise the care plan limited staffs' ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on observation and staff interview, the facility failed to store and serve food in a safe and sanitary manner in 1 of 1 kitchen. Failure to store and serve food in a safe and sanitary manner may result in contaminated food, poor food quality, and potential spread of illness amoung residents, staff, and visitors.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to provide care in a manner that maintained or enhanced dignity for 1 of 2 sampled residents (Resident #12) and 1 supplemental resident (Resident #14) observed while being fed in the dining room. Failure to feed Resident #12 and #14 in a dignified manner does not promote their dignity or enhance their quality of life.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure the residents' rights to request, refuse, and/or discontinue treatment for 1 of 13 sampled residents (Resident #17) reviewed for advance directives. Failure of staff to ensure Resident #17's family/legal representative signed documentation regarding their wishes limited the facility's ability to communicate to direct care staff and emergency personnel the family/representative's wishes in the event of a medical emergency.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to provide a written notice of transfer that included all required content, to the resident and/or their representative for 1 of 2 closed records (Resident #23) reviewed. Failure of the facility to provide a written notice with all required content to the resident/representative limited their ability to make informed decisions.

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1), and resident and staff interviews, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 13 sampled residents (Resident #16) and 1 supplemental resident (Resident #14). 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 record review, review of the North Dakota Provider Manual for 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 2 of 2 sampled residents (Resident #3 and Resident #16) with a newly diagnosed mental illness and/or change in treatment. Failure to complete a change in status assessment may result in the delivery of care and services that are inconsistent with residents' needs.

Inspectors wroteBased on record review, review of the facility policy, and staff interview, the facility failed to develop a comprehensive care plan for 1 of 13 sampled residents (Resident #16). Failure to develop a comprehensive care plan related to psychotropic medication use may negatively impact the resident's quality of care.

Inspectors wroteBased on record review, review of facility policy, and staff and resident interviews, the facility failed to provide services to maintain or improve abilities in activities of daily living (ADLs) for 3 of 9 sampled residents (Resident #12, #16, and #17) with recommendations for restorative therapy (RT). Failure to provide the residents with RT may result in decreased mobility and safety.

Inspectors wroteBased on observation, record review, facility policy review, 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 #19) dependent on staff for activities. Failure to provide meaningful activities for residents with visual impairments limited Resident #19's ability to reach his highest practicable level of physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, record review, review of professional literature, and staff interview, the facility failed to ensure 1 of 3 sampled residents (Resident #12) received the services necessary to attain the highest degree of safety possible while being fed in the dining room. Failure to ensure staff provided proper positioning and cueing when giving foods and liquids placed Resident #12 at risk for aspiration.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to provide the necessary treatment/services to promote the healing of pressure ulcers for 1 of 1 sampled resident (Resident #16) identified with a pressure ulcer. Failure to routinely assess, monitor, and measure pressure ulcers may result in delayed interventions to aid in the healing of the pressure ulcer.

Inspectors wroteBased on observation, record review, review of the facility's policy, and staff interview, the facility failed to ensure residents received adequate supervision/assistance to prevent accidents for 1 of 2 sampled residents (Resident #19) observed during stand-lift transfers. Failure to ensure proper use of a mechanical sit-to-stand lift placed Resident #19 and other residents at risk for possible accidents with/without injury.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure residents received the care and services consistent with professional standards of practice for 1 of 1 sampled resident (Resident #16) receiving hemodialysis outside the facility. Failure to ensure physician's orders for hemodialysis and to assess/monitor hemodialysis vascular access site (arterial-venous fistula) on a regular basis can result in missed dialysis appointments and complications related to the fistula.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure a regimen free of unnecessary medications for 1 of 2 sampled residents (Resident #12) with a history of urinary tract infections (UTIs). Failure obtain a culture and sensitivity (lab test to identify the bacteria and antibiotics susceptible to the bacteria) before starting an antibiotic may result in treatment for a non-existent UTI, administration of a wrong antibiotic, and the risk of experiencing side effects related to the antibiotic.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standard infection control practices for 3 of 13 sampled residents (Resident #1, #13, and #19) observed during personal cares. Failure to follow infection control practices related to hand hygiene/glove use has the potential to transmit infections to other residents, staff, and visitors.