Smp Health - Maryhill

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide adequate supervision and assistive devices necessary to ensure safety for 2 of 4 sampled residents (Resident #2 and #9) observed during transfers and ambulation. Failure to utilize gait belts and the required staff assistance placed the residents at risk for accidents and/or injury. Findings include: Review of the facility policy titled Safe Resident Handling/Transfers occurred on 09/25/25. This policy, dated May 2025, stated, . It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience . Review of the facility policy titled Standards of Care Policy occurred on 09/25/25. This policy, dated August 2025, stated, . Gait belt will be used when resident needs assistance with walking and transferring. - Review of Resident #2's medical record occurred on all days 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 observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 3 of 4 sampled residents (Resident #2, #27, and #28) observed during cares. Failure to practice infection control standards during personal cares has the potential to spread infection throughout the facility.Findings include: Review of the facility policy titled Infection Prevention and Control Program occurred on 09/25/25. This policy, revised May 2025, stated, . Institutional factors may also facilitate transmission of infections among residents. Direct/indirect contact with equipment used to provide care. Improper hand hygiene. Improper glove use. Hand hygiene continues to be the primary means of preventing the transmission of infection. Glove Hygiene . Remove and discard gloves . after every procedure that involves potential exposure to blood or body fluids. Perform hand hygiene immediately after removal of gloves . Resident dressings and supplies should be properly stored to maintain their integrity . - Observation…

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, review of facility policy, review of manufacturer's instructions, and staff interview, the facility failed to sanitize surfaces in 1 of 1 facility dining room. Failure to ensure the concentration of quaternary (quat) sanitizing solution is within manufacturer's guidelines may result in an incorrect solution concentration, inadequate sanitization of dining room surfaces, and places residents at risk for foodborne illness. Findings include: Review of the facility policy titled Cleaning Tables and Counters occurred on 09/11/24. This policy, revised February 2023, stated, . (counters, tables), apply a 200-400 ppm [parts per million] quaternary solution with a cloth . making sure that the surface remains completely visibly wet for at least 60 seconds and let air dry. Review of manufacturer's instructions for Oasis 146 Multi-Quat Sanitizer identified a concentration of 150 ppm - 400 ppm active quat for effective sanitizing. Observation in the dining room on 09/09/24 at 11:40 a.m. showed a dietary staff member (#5) wiping the kitchen serving counter and dining room…

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 and staff interview, the facility failed to comply with the North Dakota Administrative Code (NDAC), Chapter 33-43-01-20 Medication assistant I and II initial registration and renewal for 1 of 1 staff member (#4) administering medications to residents as a medication assistant (MA). Failure to ensure qualified staff administered medication increases the risk for adverse consequences. Findings include: NDAC, Section 33-43-01-20 Individuals may not be employed as a medication assistant I or medication assistant II or hold themselves out to be a medication assistant I or medication assistant II unless the individual holds a registration as a medication assistant I or medication assistant II on the department's nurse aide registry. Individuals with delegated responsibility for administration of medication to a client as a medication assistant II must hold a current status on the department's registry as a certified nurse aide . 3. Individuals may obtain initial medication assistant II registration by successfully completing a department-approved medication…

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 resident, family, and staff interviews, the facility failed to assess, develop, and implement interventions to promote dignity for 1 of 1 sampled resident (Resident #3) with concerns regarding toileting/incontinence. Failure to determine appropriate toileting methods caused Resident #3 embarrassment and/or psychosocial harm. Findings include: Review of the facility policy titled Standard of Care Policy occurred on 10/05/23. This policy, dated August 2023, stated, . Each resident is treated with dignity and respect. During an interview on 10/02/23 at 4:02 p.m., Resident #3 verbalized frustration when staff utilized that sling thing [full body lift] to get up and down. They [staff] told me to go to the bathroom in my pants. During an interview on 10/02/23 at 4:03 p.m., a family member (A) reported Resident #3 has been upset since staff started utilizing the Hoyer lift (full body mechanical lift) and stopped toileting the resident in the bathroom. A current physician ordered medication caused several loose stools per…

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 facility policy, and staff interview, the facility failed to notify the resident's physician of a change in condition for 1 of 1 sampled resident (Resident #3) who experienced a change in bowel status. Failure to notify the physician of these changes may have prevented the physician from altering the treatment/care provided to the resident. Findings include: Review of the facility policy titled Notification of Changes occurred on 10/05/23. This policy, dated 07/04/23, stated, . The purpose of this policy is to ensure the facility promptly . consults the resident's physician . Circumstances requiring notification include: . 3. Circumstances that require a need to alter treatment. Review of Resident #3's medical record occurred on all days of survey. Diagnoses included cirrhosis of the liver and metabolic encephalopathy (a brain disease). A physicians order, dated 06/02/23, stated, Lactulose Solution (a medication known to cause loose stools) 10 GM [grams]/15ML [milliliters] Give 30 ml by mouth three times a day Review of a fax sent to the facility…

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 facility policy, and staff interview, the facility failed to review and revise comprehensive care plans to reflect the residents' current status for 3 of 15 sampled residents (Resident #9, #12, and #35). Failure to review and revise the care plan limited staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Comprehensive Care Plans occurred on 10/05/23. This policy, revised August 2022, stated, . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . the care planning process will begin upon admission and ongoing with changes. - Review of Resident #9's medical record occurred on all days of survey. Diagnoses included type 2 diabetes mellitus. The physician's orders included short-acting insulin with blood glucose monitoring three times a day. Resident #9's care plan lacked problem, goals, and interventions related to diabetes mellitus. - Review of Resident #12's medical record occurred on all days of survey.…

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, review of facility policy, review of professional reference, and staff interview, the facility failed to follow professional standards of practice regarding medication administration and monitoring blood sugars for 1 of 2 sampled residents (Resident #143) and 1 supplemental resident (Resident #8) observed during medication pass. Failure to ensure the resident eats within 5-10 minutes of receiving a rapid acting insulin and failure to monitor blood sugars per physician orders may result in a hypoglycemic reaction (low blood sugar), diabetic coma and/death and failure to ensure residents receive the correct medications may result in serious adverse health effects. Findings include: Review of the facility policy titled Insulin occurred on 10/05/23. This policy, dated February 2022, stated, . Policy: It is the policy of this facility .to prevent adverse effects on a resident's condition. short acting insulin's should be administered at the start of the meal. (10 minutes max [maximum] prior to the start of eating). If a resident doesn't eat after getting insulin 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, review of facility policy, and staff interview, the facility failed to provide adequate supervision and assistive devices necessary to prevent accidents for 2 of 6 sampled residents (Resident #12 and #143) observed during a gait belt transfers. Failure to use a gait belt during transfers placed the residents at risk of accidents and injury. Findings include: Review of the policy titled Use of Gait Belt occurred on 10/04/23. This policy, dated May 2023, stated, It is the policy of this facility to use gate belts with residents that require hands on extensive assist to ambulate or transfer for the purpose of safety. Observations showed the following: * 10/03/23 at 9:49 a.m., a certified nurse aide (CNA) (#4) transferred Resident #143 from the wheelchair to the recliner without a gait belt. The CNA (#4) lifted under both of the resident's arms while the resident held onto the CNA's elbows. * 10/03/23 at 11:45 a.m., a CNA (#2) transferred Resident #12 from the toilet to the wheelchair without a gait belt. The CNA (#2) pushed upward on the resident's back and held…

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, and resident, family, and staff interviews, the facility failed to provide appropriate services and assistance to maintain bowel/bladder continence for 1 of 6 sampled residents (Resident #3) observed during toileting/incontinence care. Failure to provide toileting assistance may result in unnecessary incontinence, a loss of dignity, and avoidable skin issues. Findings include: Review of the facility policy titled Bowel and Bladder Program occurred on 10/05/23. This policy, dated April 2023, stated, . PURPOSE: [Facility Name] will provide appropriate programs and treatments for our residents . to restore and maintain as much normal bowel and bladder function as possible. During an interview on 10/02/23 at 4:02 p.m., Resident #3 verbalized frustration when staff utilized that sling thing [full body lift] to get up and down. They [staff] told me to go to the bathroom in my pants. During an interview on 10/02/23 at 4:03 p.m., a family member (A) reported Resident #3 has been upset since staff started utilizing the Hoyer lift (full body mechanical…

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 interviews, the facility failed to provide respiratory care consistent with professional standards of practice for 2 of 4 sampled residents (Resident #23 and #143) receiving oxygen by nasal cannula. Failure to administer oxygen according to the physician's order may result in complications and compromise the residents' respiratory status. Findings include: Review of the facility policy titled OXYGEN ADMINISTRATION OF occurred on 10/05/23. This policy, dated February 2022, stated, Procedure: 1. Check physician's orders . for flow rate . - Review of Resident #23's medical record occurred on all days of survey and identified a physician's order, dated 05/15/23, stated, Oxygen at 2-4 liters continuous for dyspnea per nasal cannula . Observations showed the following: * 10/04/23 at 10:26 a.m. Resident #23 received oxygen per nasal cannula at 1.5 liters per minute (LPM). * 10/05/23 at 9:29 a.m. Resident #23 received oxygen per nasal cannula at 1.5 LPM. During an interview on 10/05/23 at 9:29 a.m., a medication aide…

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, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 2 of 6 sampled residents (Resident #3 and #18) observed during personal cares. Failure to practice infection control standards related to hand hygiene has the potential to spread infection throughout the facility. Findings include: Review of the policy titled Infection Prevention and Control Program occurred on 10/04/23. This policy, dated May 2023, stated, . Glove Hygiene (Always make sure that resident is safe prior to glove removal and washing hands) . Perform hand hygiene immediately after removal of gloves . - Observation on 10/04/23 at 11:55 a.m. showed two certified nurse aides (CNAs) (#2 and #3) assisted Resident #3 with a check and change. One CNA (#3) donned gloves and performed incontinence care as the other CNA (#2) assisted with turning the resident. After removing her gloves the CNA (#3) repositioned the resident's bedside table, opened the curtain, repositioned the resident's call light, placed a pillow behind the resident's head 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.