Marian Manor Healthcare Center

Based on observation, review of facility policy, and staff interview, the facility failed to ensure proper labeling and storage of medications for 2 of 9 observations of medication preparation and administration. Failure to date an insulin pen with the open and discard date and failure to ensure medications are administered promptly after preparation may result in an ineffective dose of insulin and medication errors. Findings include:Review of the facility policy titled Medication Disposal occurred on 05/28/26. This undated policy stated, . Insulins are disposed of 28 days from the date opened unless otherwise specified by the manufacturer. These will be labeled with open and discard dates.Review of the facility policy titled Administration of Drugs occurred on 05/28/26. This undated policy stated, . Drugs are to be administered as soon as possible after doses are prepared. Medications should not be pre-dished for future medication passes.-Observation on 05/26/2026 at 5:05 p.m. showed a staff nurse (#9) prepared Resident #25's Humalog insulin pen for administration. The 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.

Based on survey findings, review of facility policy, professional reference, and staff interview, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to develop a Performance Improvement Project (PIP) to decrease or prevent the likelihood of problems or occurrences of adverse events, and ensure compliance with federal requirements related to a resident choking incident. Findings include:Review of the facility Quality Assurance and Performance Improvement Plan occurred on 05/28/26. The undated policy stated, . Scope . we provide comprehensive clinical care to residents . all care is resident-centered and focuses on choice and Individualized plans of care . Implementation . will be carried out by the Quality Assurance and Performance Improvement Plan Committee (QA), which . assures that the monitoring activities selected effectively cover all types of services and categories of care rendered . The facility conducts PIPs to examine and improve care and/or services in specifically identified areas. PIPs are chosen based on their importance 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 review of the Electronic Staffing Data Submission Payroll-Based Journal (PBJ) Long-Term Care Facility Policy Manual and staff interview the facility failed to submit direct care staffing information based on payroll data to the Electronic Staffing Data Submission PBJ for 1 of 4 reporting periods (Quarter #4). Failure to submit direct care staffing information may result in inaccurate representation of the level of staff in the facility which can impact the quality of care delivered. Findings include: The June 2022, version 2.6 Electronic Staffing Data Submission Payroll-Based Journal (PBJ), pages 1-3, stated, . Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate . Facilities that do not meet these requirements will be considered noncompliant and subject to enforcement actions by CMS [Centers for Medicare and Medicaid Services] . Review of the PBJ Data Staff Report CASPER Report (a CMS report) 1705D FY (fiscal year) Quarter 4 (July 1 - September 30, 2024) occurred on 03/12/25, and stated, . Failed to Submit Data for 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 record review, review of facility policy, review of the facility investigation report, and staff interview, the facility failed to report an incident of potential neglect to the State Survey Agency (SSA) for 1 of 1 sampled resident (Resident #38) who experienced a burn from an electric heating pad. Failure to report an event of potential neglect to the SSA in the required time frame placed Resident #38 and other residents at risk for burns. Findings include: Review of the facility titled ABUSE PROHIBITION PLAN occurred on 03/11/25. This policy, dated December 2024, stated, The resident has the right to be free from . neglect . Neglect includes the failure of the facility, its employees, or service providers to provide goods or carry out resident services as directed or ordered by the physician or other authorized personnel necessary to avoid physical harm, pain, mental anguish or emotional distress. Failure to give proper attention to residents, or failure to carry out resident services through indifference, disregard for patient care, or careless oversight are examples 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 facility policy, and staff interview, the facility failed to ensure the resident or their representative chose to accept or decline a bed hold for 2 of 3 sampled residents (Resident #38 and #46) reviewed for hospitalizations. Failure to obtain a resident or their representative's bed hold choice does not allow the resident and/or their representative to make an informed decision regarding their rights. Findings include: Review of the facility policy titled Bed Hold occurred on 03/13/25. This policy, dated December 2024, stated, Notices of the . Bed Hold/Release notice will be given at each hospitalization . The resident or responsible party is to choose which they would like either to hold or release the bed . - Review of Resident #38's medical record occurred on all days of survey and identified a hospitalization on 01/29/25. The record failed to identify if the resident and/or their representative accepted or declined a bed hold. An office staff member (#6) provided an undated and unsigned bed hold form for the hospital stay. The office staff…

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 record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 12 sampled residents (Resident #30). 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. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2024, page A-32, stated, . Complete if A0310A = 01 . Annual assessment . Coding Instructions Code A, Serious mental illness: if resident has been diagnosed with a serious mental illness . Review of Resident #30's medical record occurred on all days of survey. The medical record included the diagnosis of paranoid schizophrenia. The facility failed to code the serious mental illness on the annual MDS, dated [DATE]. During an interview on…

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 care plans to reflect the residents' current status for 3 of 12 sampled residents (Resident #21, #22, and #38). Failure to update care plans limited the staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Nursing Care Plans occurred on 03/12/25. This policy, dated December 2024, stated, A nursing care plan directs the resident's nursing care . The Care plan should be written individually for each resident, making it resident-centered. Planning is to be continuous (on-going) . Review of the facility policy titled Trauma Informed Care occurred on 3/12/25. This policy, dated December 2024, stated, . The facility will collaborate with resident trauma survivors . to develop and implement individualized care plan interventions. Trigger specific interventions will identify ways to mitigate or decrease the effect of the trigger . and will be added to the resident's care plan. - Review of Resident…

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 prepare, store, and serve food in a sanitary manner in 1 of 1 kitchen. Failure to discard outdated food items and monitor the sanitizer concentration may result in unsafe food storage/preparation and foodborne illness. Findings include: OUTDATED FOOD ITEMS Review of the facility policy titled Food Safety Requirements occurred on 01/25/24. This policy, revised January 2024, stated, . Practices to maintain safe refrigerated storage include . Labeling, dating, and monitoring refrigerated food . so it is used by its use-by date, or . discarded . Observation of the kitchen on 01/22/24 at 11:00 a.m. and 01/24/24 at 11:18 a.m. showed six quart-sized cartons of buttermilk sitting on a shelf in the walk-in refrigerator. Each carton was dated 01/06/24 (19 days past the use-by date). A managerial dietary staff member (#3) confirmed she would discard the outdated buttermilk. SANITIZER Review of the facility policy titled Sanitation Inspection occurred on 01/25/24. This policy, revised January 2024,…

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 the North Dakota Plumbing Code, and staff interview, the facility failed to provide an air gap for 1 of 1 two-compartment sink observed in the main kitchen. Failure to provide the required air gap for a two-compartment sink has the potential to allow contamination of the sink in the event of a sewer back up. Findings include: Review of the 2018 North Dakota Plumbing Code, Section 801.2 Air Gap or Air Break Required, stated, Indirect waste piping shall discharge into the building drainage system through an air gap or air break as set forth in this code. Where a drainage air gap is required by this code, the minimum vertical distance as measured from the lowest point of the indirect waste pipe or the fixture outlet to the flood-level rim of the receptor shall be not less than 1 inch (25.4 mm). Section 801.3.3 Food-Handling Fixtures, stated, Food-preparation sinks, steam kettles, potato peelers, ice cream dipper wells, and similar equipment shall be indirectly connected to the drainage system by means of an air gap. Bins, sinks, and other equipment…

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 provide the resident or the resident's representative a written notice of transfer for 1of 1 resident (Resident #22) 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. Findings include: Review of Resident #22's medical record occurred on all days of survey. A hospital transfer occurred on 12/21/23. The medical record lacked documentation the facility provided the resident and/or representative with a written transfer notice. During an interview on 01/24/24 at 4:45 p.m., an administrative staff member (#2) confirmed the facility failed to provide written notice of a transfer to the family/representative.

Based on record review, review of facility policy, and staff interview, the facility failed to provide the resident or resident's representative a written bed hold notice for 1 of 1 resident (Resident #22) reviewed for hospital transfer. Failure to provide a written copy of the bed hold notice and include the reserve bed amount does not allow the resident and/or their representative to make an informed decision regarding their rights. Findings include: Review of the facility policy Bed Hold occurred on 01/25/24. This undated policy, stated, Before a resident is transferred to a hospital or goes on therapeutic leave, the facility will provide written information to the resident and a family member or legal representative that specifies the duration of the bed-hold policy. The resident, or a person acting on behalf of the resident, must request that the bed be held and informed of the charges. Review of Resident #22's medical record occurred on all days of survey. A hospital transfer occurred on 12/21/23. The medical record lacked documentation the facility provided the resident…

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 record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 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 7 residents (Resident #4 and #31) prescribed Aspirin. Failure to accurately complete the MDS for medications taken by the residents may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI User's Manual, dated October 2023, pages N-1, and N-6 to N-8 stated, Section N Medications . N0415: High-Risk Drug Classes . Coding Instructions: Code all high-risk medications according to their pharmacological classification, not how they are being used. N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g., [for example] aspirin/extended release . ) was taken by the resident at any time during the 7-day observation period . - Review of Resident #4's medical record occurred on all…

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.