Baptist Health & Rehab

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide appropriate treatment/services to prevent complications from a gastrostomy tube (G-tube) (a tube inserted through the abdomen that brings nutrition directly to the stomach) for 1 of 1 sampled resident (Resident #47) observed with a G-tube. Failure to flush the tube with water before and after medications may lead to dehydration and G-tube occlusion. Findings include: Review of the facility policy titled Medication via enteral tube occurred on 04/16/25. This policy, dated 06/26/23, stated, . Administering each medication separately and flushing between each medication is considered standard of practice . flush tube with 30 cc [cubic centimeters] of water . administer each prepared medication flushing with 5-10 cc warm water after each medication. attach syringe to feeding tube and flush it with 30 cc warm water . Review of Resident #47's medical record occurred on all days of survey and identified G-tube placement. Observation on 04/14/25 at 3:37 p.m. showed a nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and review of facility policy, the facility failed to follow standards of infection control and prevention for 3 of 6 sampled residents (Residents #49, #73 and #436) on enhanced barrier precautions (EBP) and observed during cares. Failure to follow EBP during tracheostomy (an opening through the neck into the windpipe) and percutaneous gastrostomy (PEG) tube (feeding device inserted into the stomach through the abdomen) care for Resident #49, tracheostomy care (cleaning the airway tube and surrounding skin) for Resident #436, and wound care for Resident #73 has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Transmission-based precautions and enhanced barrier precautions occurred on 04/16/25. This policy, revised 05/03/24, stated, . requiring gown and glove use for enhanced barrier precautions include . feeding tube, tracheostomy/ventilator . Wound care: Any skin opening requiring a dressing . - Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, review of the facility reported incident, review of facility policy, and staff interview, the facility failed to report an incident of abuse within 24 hours to the State Survey Agency (SSA) for 1 of 1 sampled resident (Resident #2) who experienced an injury. Failure to report an event of potential abuse in the required time frame does not comply with regulations established to protect residents. This citation is considered past noncompliance based on review of the corrective action the facility implemented. Findings include: The surveyor determined a deficient practice existed on 11/02/24. The facility implemented and completed corrective action on 11/08/24. Review of the facility policy titled Vulnerable Adult - ND [North Dakota] occurred on 01/23/25. This policy, dated 10/14/22, stated, . Report all alleged violations . no later than 24 hours if the events that cause the allegation do not involve abuse or do not result in serious bodily injury to the North Dakota Department of Health . The facility investigation report stated, . On Friday 11/01/24, at the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to assess the use of a wheelchair seatbelt and vest straps as a possible restraint for 1 of 2 sampled residents (Resident #2) observed with a wheelchair seat belt and vest straps . Failure to assess the wheelchair seatbelt and vest straps as possible restraints, monitor their use, and evaluate the need for continued use placed Resident #2 at risk for an unnecessary restraint and injury related to their use. Findings include: Review of the facility policy titled Physical assistive device assessment occurred on 03/07/24. This policy, dated 02/27/23, stated, . When appropriate, physical assistive devices will be used for resident safety, assisting with positioning or mobility and/or to help achieve and maintain a resident's highest practicable level of functioning. All assistive devices will be assessed by the interdisciplinary team to assess the risk versus benefit of the device. *Prior to initiation of the device. *A quarterly review of the assessment with the MDS [Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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 3 of 28 sampled residents (Resident #2, #63, and #99). Failure to review and revise the care plan limited staff's ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Care plan and baseline care plan occurred on 03/07/24. This policy, revised 10/14/22, stated, . The resident care plan is constantly changing. It is to be updated routinely in the electronic record to reflect resident's current condition. Care plans are updated with MDS [Minimum Data Set] /Care conference schedule and as needed to assure that they are an accurate reflection of the resident and their care needs. - Review of Resident #2's medical record occurred on all days of survey. The current care plan stated, Impaired physical mobility: potential for falls r/t [related to] impaired mobility . W/C [wheelchair] for locomotion. Observations on 03/04/24 at 4:28 p.m. and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to follow professional standards of nursing practice for 1 of 1 supplemental resident (Resident #135) observed during medication administration. Failure of staff to ensure residents swallowed medications, reported behaviors during medication administration, and re-administered unswallowed or refused medications may lead to adverse health conditions. Findings include: Review of the facility policy titled Medication administration occurred on 03/07/24. This policy, revised 07/18/19, stated, . Medications will be administered by licensed nurses or trained medication aides . under the supervision of a licensed nurse. Review of Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th ed., Pearson Education, Inc., Massachusetts, page 837, stated, . Administering Medications Safely . Some older people may be confused by the prescription of several medications and may passively accept their medications from nurses but not swallow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of facility policy, and family 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 5 sampled residents (Resident #60) dependent on staff for activities. Failure to provide meaningful activities for residents limited Resident #60's ability to reach her highest practicable level of physical, mental, and psychosocial well-being. Findings include: During an interview on 03/05/24 at 10:50 a.m., a family member (A) stated, [Resident #60] sits out by the nurses' station. They [residents] are always sitting in the lounge. They are lined up and not stimulated. Not one aide will be sitting there, engaging them. I can go up any time of the day, but there is no one interacting with them. Review of the facility policy titled One to One Therapeutic Activity Programs occurred on 03/07/24. This policy, revised 05/01/22, stated, . One to One Activity programs will…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, review of professional reference, review of facility policy, and family interview, the facility failed to offer fluids to 1 of 3 sampled residents (Resident #60) who were observed during cares and required staff assistance for fluid intake. Failure to provide assistance with fluid intake may result in dehydration, constipation, and urinary tract infections (UTIs). Findings include: During an interview on 03/05/24 at 10:50 a.m., following cares, a family member (A) indicated staff often fail to offer liquids, stating, Here [on the bedside table] sits her [Resident #60's] water. She's had three UTIs in the last few months. Review of the facility policy titled Hydration occurred on 03/07/24. This policy, dated 04/13/23, stated, . Each resident will receive and the facility will provide fluids, including water and other liquids consistent with resident needs and preferences and sufficient to maintain proper hydration . CNA [certified nurse aide] staff will provide and encourage intake of fluids on a daily and routine basis as part of daily care.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, policy and procedure review, professional reference review, and resident and staff interviews, the facility failed to provide the care and services consistent with professional standards of practice for 2 of 3 sampled residents (#79 and #99) on hemodialysis with an arterial-venous fistula (vascular access for hemodialysis). Failure to assess the hemodialysis vascular access site (fistula) may result in complications and adverse effects, such as clotting and possible loss of the access site. Findings include: Review of the facility policy titled Dialysis occurred on 03/05/24. This policy, dated 11/06/23, stated, Responsibility: Licensed Nurse 1. Residents who require dialysis will receive this service consistent with professional standards of practice . 2. Facility will provide ongoing assessment of the resident's condition and will monitor for complications before and after each dialysis treatment received at a certified dialysis facility. 4. The coordinated, person-centered care plan will include: . f. Adverse responses/complications to dialysis and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, facility policy review, and staff interview, the facility failed to follow standards of infection control for 3 of 10 sampled residents (#60, #124, and #131) observed during cares. Failure to follow infection control standards during perineal cares and with transmission-based precautions (TBP) has the potential to transmit infections to residents, staff, and visitors. Findings include: TRANSMISSION BASED PRECAUTIONS Review of the facility policy titled COVID -19 protocol occurred on 03/05/24. This policy, dated 09/16/20, stated, . Employees providing care for COVID-19 positive residents will wear N-95 masks, gown, gloves and eye protection . Review of Resident #131's medical record occurred on all days of survey. The progress notes identified the following: * 03/01/2024 at 4:22 p.m., . [resident] is being admitted to the hospital. tested Covid + [positive] . * 03/03/2024 at 6:53 p.m., Resident returned from the hospital. Resident was diagnoses [sic] with COVID on 3/01/24. Resident is on Droplet and contact isolation . Observations showed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.