Smp Health - Ave Maria

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy, and staff interviews, the facility failed to ensure 1 of 1 supplemental resident (Resident #35) was free from resident-to-resident abuse. Failure to assess, care plan, and follow the plan/process may result in physical harm, fear, anxiety, and psychosocial harm to all residents. Findings include: Review of the facility policy titled, Abuse occurred on 12/11/25. This policy, dated January 2025, stated, Each resident has the right to be free of verbal . abuse . To ensure these rights SMP [Sisters [NAME] of the Presentation] Health-Ave [NAME] has developed and implemented policies and procedures, which include the components of screening, training, prevention, identification, protection, investigation, and reporting/response. Verbal abuse is defined as . intimidation . mental anguish .Review of the facility policy titled, Behavior Management occurred on 12/11/25. This policy, dated January 2025, stated, . POLICY: Behavior monitoring and assessment will be carried…

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 report incidents of resident-to-resident abuse to the State Survey Agency (SSA) for 1 of 1 supplemental resident (Resident #35) who experienced verbal abuse. Failure to report resident-to-resident abuse allegations places all residents at risk of potential abuse/neglect. Findings include: Review of the facility policy titled, Abuse occurred on 12/11/25. This policy, dated January 2025, stated, Each resident has the right to be free of verbal . abuse . Procedure .Any alleged incident must be reported to the North Dakota Health Department immediately (within 24 hours or less) .- Review of Resident #35's medical record occurred on 12/10/25 and identified an admission date of 10/10/25. Resident #4 was moved to the same room as Resident #35 on 10/22/25.- Review of Resident #4's medical record occurred on all days of survey. The nursing progress notes showed the following: * 11/24/25 at 10:24 p.m., stated, . calling room mate [sic] vulgar names and telling staff to 'knock him out' .* 12/08/25 at…

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 interviews, the facility failed to investigate an incident of resident to resident abuse for 1 or 1 supplemental resident (Resident #35) who experienced verbal abuse. Failure to investigate incidents of abuse may result physical harm, fear, anxiety, and psychosocial harm for all residents Findings include: Review of the facility policy titled, Abuse occurred on 12/11/25. This policy, dated January 2025, stated, Each resident has the right to be free of verbal . abuse . To ensure these rights . policies and procedures, which include . investigation . All alleged abuse will be investigated by the Director of Nursing .- Review of Resident #35's medical record occurred on 12/10/25 and showed an admission date of 10/10/25 and Resident #4 was moved to the same room as Resident #35 on 10/22/25.- Review of Resident #4's medical record occurred on all days of survey. Review of the progress notes showed the following: * 11/24/25 at 10:24 p.m., stated, . calling room mate [sic] vulgar names and telling staff to 'knock him out' .*…

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 ensure staff provided necessary care and services for 1 of 1 sampled resident (Resident #4) with diabetes. Failure to follow physician orders for out-of-range blood sugar levels may result in adverse health events.Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 63, stated, . It is the nurse's responsibility to seek clarification of ambiguous or seemingly erroneous orders from the prescriber. If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out. Review of Resident #4's medical record occurred on all days of survey. Diagnoses included diabetes mellitus. The current care plan stated, [Resident] has Diabetes mellitus with polyneuropathy [a degeneration of peripheral nerves]. will be free from any s/sx [signs/symptoms] of hyperglycemia [high blood sugar] . will be free from any s/sx of hypoglycemia [low blood sugar] . will have no complications related to diabetes…

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, facility policy review, and staff interview, the facility failed to follow standards of infection control for 2 of 9 sampled residents (Resident #3 and #25) and 2 supplemental residents (Resident #50 and #70) observed during cares/dressing change and glucose monitoring. Failure to follow infection control practices during resident cares related to hand hygiene, enhanced barrier precautions (EBP), and cleaning of a glucometer has the potential to spread infection throughout the facility. Findings include: HAND HYGIENE Review of the facility policy titled Hand Hygiene occurred on 09/11/24. This policy, revised July 2024, stated, . Hand Hygiene Should Be Practiced: . Before applying and after removing gloves. Review of the facility policy titled Dressing: Clean occurred on 09/11/24. This policy, dated June 2024, stated, . [NAME] [put on] clean gloves and remove the dressing. Dispose of the gloves, perform hand hygiene and don a clean pair of gloves. Apply dressing to the area as…

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 Long Term Care Ombudsman Program Guide to Resident Rights, and staff interview, the facility failed to provide care in a manner that promoted, maintained, or enhanced the resident's dignity for 1 of 2 sampled residents (Resident #3) with a wound vacuum. Failure to cover a wound vacuum collection container does not preserve the resident's personal dignity and/or enhance their quality of life and has the potential to affect the resident's psychosocial well-being. Findings include: The North Dakota Long Term Care Ombudsman Program's Guide to Resident Rights, updated 03/21/23, page 16, stated, . The facility must treat you courteously, fairly and with dignity. Observation on 09/10/24 at 11:21 a.m. showed Resident #3 sitting in the hallway in front of the television with the wound vacuum and its contents visible. Observation on 09/10/24 at 11:44 a.m. showed Resident #3 sitting in the hallway in front of the television with a hand towel partially covering the wound vacuum canister, however, the contents of the wound vacuum canister remained…

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 ensure accurate labeling of medications for 1 of 4 residents (Resident #70) observed receiving medication from an injector pen. Failure to obtain a label for an insulin pen may result in a resident receiving the wrong medication or an incorrect dose. Findings include: Review of a policy titled Medication Storage/Labeling occurred on 09/11/24. This policy, revised July 2024, stated, . Medications are labeled by pharmacy. If receiving medications from any mail order pharmacies that are not labeled individually, label with resident identification information . Observation on 07/10/24 at 8:17 a.m. showed a nurse (#1) prepared Resident #70's Novolog insulin pen for administration. The pharmacy label on the pen lacked a legible label with the resident's name or other identifying information. During an interview on 09/11/24 at 2:44 p.m., an administrative nurse (#2) confirmed Resident #70's Novolog insulin pen lacked a legible label.

Based on observation, record review, and staff interview, the facility failed to provide treatment in accordance with the resident's plan of care for 1 of 2 sampled residents (Resident #49) with a history of a diabetic heel ulcer. Failure to apply heel protecting boots as ordered may result in the reoccurrence or worsening of heel ulcers. Findings include: Review of Resident #49's medical record occurred on all days of survey. Diagnoses included Type II Diabetes Mellitus and a history of diabetic heel ulcer (healed in August 2023). A physician's order, dated 08/22/23, stated, Prevalon boot [heel protecting soft boots] to BLE [bilateral lower extremities] when in bed. Observations on the morning of 10/10/23 and afternoon of 10/10/23 showed Resident #49 resting in bed without heel boots on her feet. Observation showed her heels rested on the mattress. During an observation on the afternoon of 10/11/23, a nurse (#2) entered Resident #49's room, gave the heel boots to two certified nurse aides (CNAs) (#3 and #4), and indicated Resident #49 needed to wear them in bed.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure residents' records contained the hospice election form and the certification of a terminal illness for 3 of 4 sampled residents (Resident #53, #86, and #88) receiving hospice services. Failure to obtain these documents limits staff's ability to ensure coordination of care between the facility and the hospice. Findings include: Review of the facility policy titled Hospice Care occurred on 10/11/23. This policy, dated January 2022, stated, . Documentation and maintenance of the hospice record: [name of facility] will maintain its own resident documentation system . physician orders and other relevant documentation in order to facilitate communication between the caregivers. - Review of Resident #53's medical record occurred on all days of survey. Resident #53 elected Hospice services on 08/11/23. The medical record lacked the Certificate of Terminal Illness completed by the Hospice provider. - Review of Resident #86's medical record occurred on all days of survey. 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.