St. Vincent's - a Prospera Community

Inspectors wroteBased on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 5 of 13 residents (Resident #5, #6, #11, #77, and #80) observed during medication administration. Six medication errors occurred during staff administration of 49 medications which resulted in a 12 percent error rate. Failure to follow and/or clarify physician's orders and pharmacy recommendations may inhibit the effectiveness of the medication, cause subtherapeutic levels, and may have a negative impact on the resident's overall health.

Inspectors wroteBased on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to provide care in accordance with professional standards for 1 of 1 sampled resident (Resident #6) with a peg tube (tube inserted in the stomach) and a peripherally inserted central catheter (PICC) (long term intravenous (IV) line). Failure to verify placement and patency of a peg tube prior to use, administer medications in prescribed forms and in individual doses, follow and/or clarify physician's orders, and document medications/treatments as completed on the correct date may result in adverse consequences to the resident.

Inspectors wroteBased 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 #3) reviewed for antipsychotic medications. Failure to complete a baseline assessment before starting an antipsychotic may result in undetected side effects and adverse consequences related to the antipsychotic medication.

Inspectors wroteBased on observation, record review, review of professional reference, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 1 sampled resident (Resident #6) observed with a peripherally inserted central catheter (PICC) (long term intravenous (IV) line) during cares. Failure to practice infection control standards related to hand hygiene, glove use, and accessing PICC lines may result in adverse consequences to the resident and has the potential to spread infection throughout the facility.

Inspectors wrote1. Based on record review, review of facility policy, and resident, family, and staff interviews, the facility failed to ensure residents remained free from physical and mental abuse for 1 of 1 confidential resident (Resident A) with allegations of abuse. Failure to provide services necessary to avoid mental/emotional distress and physical harm resulted in fear and an unsafe environment for Resident A and has the potential for all residents to experience psychosocial harm.

Inspectors wroteBased on observation, record review, and review of the North Dakota Resident's Rights Guide, the facility failed to ensure residents remained free of chemical restraints for 1 of 1 sampled resident (Resident #37) with an as needed (PRN) psychotropic medication. Failure to assess resident behaviors in an effort to determine causative/precipitating factors, develop a behavioral care plan, and implement individualized interventions in an attempt to manage behaviors resulted in the frequent utilization of psychotropic medications to control Resident #37's behavior.

Inspectors wroteBased on observation, review of facility policy, test tray, and resident interviews, the facility failed to serve foods at palatable temperatures in 3 of 3 units ([NAME] Place, Sacred Heart Place, and [NAME] Place). Failure to serve food at a temperature that is acceptable and palatable to residents' places residents at risk of decreased intake, weight loss, and nutritional decline.

Inspectors wroteBased on observation, review of professional reference, and staff interview, the facility failed to maintain cold storage areas and kitchen equipment in a sanitary manner for 1 of 1 kitchen. Failure to clean fans, ceilings, walls in areas where food is stored and failure to ensure a cleanable surface for kitchen equipment has the potential for contamination of food and may result in a foodborne illness. Findings Include: The 2022 Food and Drug Administration (FDA) Food Code, Chapter 3 Food, Section 3-305 Preventing Contamination From the Premises, Section 3-305.11 states, A. Food shall be protected from contamination by storing the food: . 2) Where it is not exposed to . dust, or other contamination. The 2022 Food and Drug Administration (FDA) Food Code, Annex 3, Chapter 4 Equipment, . Section 4-101.11 Characteristics . [...]

Inspectors wroteBased on review of the State Agency (SA) facility files, survey findings, review of facility policy, and staff interview, the facility failed to develop a Quality Assurance and Performance Improvement (QAPI) process to evaluate and identify problems and opportunities to improve services/outcomes, decrease or prevent likelihood of problems or occurrence of adverse events, and ensure compliance with federal requirements.

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 5 of 23 sampled residents (Residents #37, #76, #243, and #443). Failure to update care plans limited the staffs' ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on observation, record review, review of facility policy, review of facility assessment, review of resident council meeting minutes, review of call light logs, review of staffing schedule, confidential resident and family interviews, and staff interviews, the facility failed to ensure sufficient nursing staff and related services are available at all times to meet the residents' needs for 2 of 23 sampled residents (Resident #243 and #293) and 11 confidential residents (Resident A, B, C, D, E, F, G, H, I, J, and K) who required staff assistance. Failure to provide sufficient staffing does not promote each resident's rights, physical, mental, and psychosocial well-being, and/or provide a safe environment for the residents.

Inspectors wroteBased on observation, review of facility policy and staff interview, the facility failed to provide care in a manner that maintained, enhanced, and respected the resident's dignity and individuality for 2 of 2 supplemental residents (Resident #6 and #16) who received insulin and blood glucose checks. Failure to administer insulin and perform blood glucose checks in a private area does not preserve the resident's personal dignity, infringes upon the resident's rights to privacy, and has the potential to affect the resident's psychosocial well-being.

Inspectors wroteBased on record review, review of the facility's policy, and staff interview, the facility failed to ensure the right to participate in the development and implementation of the person-centered plan of care for 1 of 1 sampled resident (#243) reviewed for care planning. Failure to afford Resident #243 and/or a family representative the opportunity to participate in the care planning process restricted their right to make decisions/provide input regarding any potential changes to Resident #243's care, treatment, and/or interventions.

Inspectors wroteBased on record review, review of the facility's policy, and resident, family, and staff interviews, the facility failed to ensure all alleged violations involving abuse were reported immediately to the administrator of the facility and to other officials (including the State Survey Agency) for 1 of 1 sampled resident (Resident #243) and 1 confidential resident (Resident A). Failure to report Resident A's allegation of abuse to the state agency, and an incident involving Resident #243 and another resident to the administrator and State agency placed all residents at risk of mistreatment, verbal abuse, and/or experiencing anxiety/fear.

Inspectors wroteBased on record review, review of facility policy, and resident, family, and staff interviews, the facility failed to thoroughly investigate alleged violations of abuse for 1 of 1 sampled resident (Resident #243) and 1 confidential resident (Resident A). Failure to thoroughly investigate Resident #243's incidents of abusive behavior and Resident A's allegations of abuse, ensure the protection of other residents during the investigation, implement corrective actions, and evaluate the effectiveness of the actions, placed all residents at risk for mistreatment, verbal abuse, and/or experiencing anxiety/fear.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to provide the resident or the resident's representative a written notice of transfer or a copy of the notice to the State Long Term Care Ombudsman for 2 of 6 sampled residents (Resident #78 and #243) 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 and does not allow the ombudsman to be aware of facility practices regarding transfer and discharge or advocate on the resident's behalf.

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual and staff interview, the facility failed to complete a significant change in status assessment (SCSA) for 1 of 3 sampled residents (Resident #37) who experienced a significant change in status. Failure to determine the need for and complete a SCSA in response to a resident's decline limited the facility's ability to accurately assess the resident's status and identity and implement appropriate care approaches.

Inspectors wroteBased on record review, review of professional reference, and staff interview, the facility failed to follow professional standards of practice for 1 of 1 sampled resident (Resident #1) with high blood glucose readings. Failure to notify the provider of high blood glucose levels as ordered may result in adverse outcomes for the resident.

Inspectors wroteBased on observation, record review, review of professional reference, and staff interview, the facility failed to provide appropriate toileting and perineal care for 1 of 4 sampled residents (Resident #293) observed for toileting who required staff assistance. Failure to provide toileting assistance as care planned and proper perineal care may result in a loss of dignity and placed the resident at risk for skin breakdown, decreased self-esteem, and urinary tract infections (UTI).

Inspectors wrote1. Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide adequate assessment and/or assistive devices necessary to prevent accidents for 2 of 7 sampled residents (Resident #25 and #37) who required assistance with transfers. Failure to provide appropriate assessment and use assistive devices during transfers placed the residents at risk of accidents and injury.

Inspectors wroteBased on record review, review of facility policy and staff interview, the facility failed to ensure medication orders include a rationale and duration for the use of an as needed (PRN) psychotropic medication for 1 of 1 sampled resident (Resident #37) who received PRN psychotropic medications. Failure to ensure PRN psychotropic medication orders are limited to 14 days and document a rationale for continued use places residents at risk for receiving unnecessary medications and experiencing adverse consequences related to their use.

Inspectors wroteBased on observation, facility policy, record review and staff interview the facility failed to ensure accurate reconciliation and storage of medications for 1 of 2 sampled residents (Resident #68) observed during medication pass. Failure to reconcile and dispose of medications may result in medications errors and the potential for drug diversion.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 5 sampled residents (Resident #78) in Enhanced Barrier Precautions (EBP) and 1 of 4 sampled residents (Resident #25) who required staff assistance with perineal care. Failure to practice infection control standards related to EBP, urinary catheter care, and perineal care has the potential to spread infection throughout the facility.

Inspectors wroteBased on observation and review of facility policy, the facility failed to ensure posting of accurate staffing information on 2 of 4 days of survey (March 31 and April 2, 2025). 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.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services for 1 of 5 sampled residents (Resident #77) identified with weight loss. Failure to evaluate Resident #77's weights, monitor intake of nutritional supplements, and implement additional interventions resulted in a significant weight loss.

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 proper monitor the sanitizer concentration may result in a foodborne illness.

Inspectors wroteBased on information provided by complainants, observation, and staff, resident, and family interviews, the facility failed to ensure sufficient staff available to promptly respond to residents' call lights for 2 of 20 sampled residents (Resident #20 and #50) and 3 of 3 confidential residents (Resident A, B, and C) who require staff assistance. Failure to promptly respond to resident calls for assistance may result in residents experiencing unmet needs and may negatively affect the residents' physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to ensure the safe and secure storage of medications, accurately label multi-dose insulin pens, and properly store medications and vacutainer tubes (blood draw tubes) in 3 of 3 medications carts/rooms (Sacred Heart Place, [NAME] Place, and [NAME] Place). Failure to ensure proper storage of medications, correctly label multidose insulin pens with an open/discard date, ensure an appropriate label and discard expired medications and vacutainer tubes increases the risk of residents receiving the wrong medication, outdated medications, and staff utilizing outdated laboratory supplies.

Inspectors wroteBased on information received from the complainant, observation, review of facility policy, and resident, family, and staff interviews, the facility failed to serve foods at palatable temperatures in 2 of 3 units (Scared Heart Place and [NAME] Place). Failure to serve foods at a temperature acceptable to residents may result in decreased intake, weight loss, and inadequate nutrition.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 4 of 20 sampled residents (Resident #9, #20, #77, and #79) observed and for 2 of 3 (Sacred Heart Place and [NAME] Place) utility rooms. Failure to practice infection control standards related to hand hygiene, glove use, clean surfaces, follow transmission based precautions (TBP), and ensure the availability of proper personal protective equipment (PPE) in the soiled utility rooms has the potential to spread infection throughout the facility.

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 1 of 20 sampled residents (Resident #76) and 1 supplemental resident (Resident #18). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the development of a comprehensive care plan and the care provided to the residents.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 2 of 20 sampled residents (Resident #39 and #77). Failure to revise the care plan for Resident #39 and follow the care plan for Resident #77 limited the staff's ability to communicate care needs and ensure continuity of care for each resident.

Inspectors wrote1. Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services to 1 of 3 sampled residents (Resident #19) with skin tears. Failure to assess/document the cause and reassess/monitor current skin issues and treatments has the potential for further skin breakdown and resident discomfort.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to ensure care and services to prevent complications of enteral feeding for 1 of 1 sampled resident(Resident #19) observed with gastrostomy tube (PEG) (a tube inserted through the abdomen that brings nutrition directly to the stomach) feedings. Failure to flush the tube with the correct amount of water before and after feeding administration may lead to dehydration and other complications.

Inspectors wroteBased on observation, record review, review of facility policy, and resident and staff interviews, the facility failed to provide respiratory care for 1 of 7 sampled residents (Resident #78) and 1 supplemental resident (Resident #52) receiving oxygen by nasal cannula. Failure to administer oxygen according to the physician's order and maintain clean equipment may result in complications and compromise the residents' respiratory status.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 1 of 1 sampled resident (Resident #44) and two supplemental residents (Resident #12 and #31) observed receiving insulin. Four medication errors occurred during staff administration of 29 medications, resulting in an 13% error rate. Failure to properly prepare and administer medications may result in residents receiving an ineffective dose and experiencing adverse reactions.