Nelson County Health System Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility reported incident (FRI) investigations, review of facility policy, and resident interview, the facility failed to ensure residents remain free from abuse for 2 of 2 sampled residents (Resident #2 and #4) who were subjected to physical abuse by Resident #1. Failure to protect residents from physical abuse may result in injury, fear, anxiety, mental anguish, and emotional distress.Findings include:Review of the facility policy, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, occurred on 04/29/26. This policy, dated 07/07/21, stated, . all residents have the right to be free from verbal, sexual, physical . abuse . Residents must not be subject to abuse by anyone, including, . other residents .Incident between Resident #1 and #4Review of the facility's initial FRI investigation, dated 01/25/26 at 9:30 p.m. stated, . Incident happened in the west hallway where [Resident#1] grabbed another residents [Resident #4] arm and grabbed, pulled, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the facility reported incident (FRI) investigations, review of facility policy, and resident interviews, the facility failed to investigate alleged violations of abuse for 2 of 2 sampled residents (Resident #2 and #4). Failure to investigate Resident #1's incidents of abusive behavior, 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. Findings include:Review of the facility policy titled Abuse, Neglect, Mistreatment, and misappropriation of Resident Property occurred on 04/29/26. This policy, dated 07/07/21, stated, . The investigation is the process used to try to determine what happened. The nurse begins the investigation immediately. A root cause investigation and analysis will be completed . The investigation will consist of at least the following . An interview with staff members having…

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 facility reported incident (FRI) and investigation, review of facility policy, and staff interview, the facility failed to ensure residents remained free from abuse for 1 of 1 sampled resident (Resident #1) who displayed physical behaviors towards other residents. Failure to provide necessary services to protect residents from abuse resulted in physical abuse. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include: The surveyor determined a deficient practice existed on 06/17/25. The facility implemented and completed corrective action on 06/23/25. Review of the facility policy titled Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property occurred on 06/24/25. This policy, revised 07/07/21, stated, . It is the policy of the [facility] that all residents have the right to be free from . physical . abuse . PHYSICAL ABUSE includes hitting, slapping,…

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 1 of 2 sampled residents (Resident #9) observed with an indwelling catheter. Failure to practice infection control standards related to enhanced barrier precautions (EBP), urinary catheters, and hand hygiene has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Enhanced Barrier Precautions occurred on 04/01/25. This policy, dated April 2024, stated, . Enhanced Barrier Precautions refers to the use of gown and gloves for certain residents during specific high-contact resident care activities that have been found to increase risk for transmission of multidrug-resistant organisms. Signage will be posted on the door or wall of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. High-contact resident care activities . Transferring…

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 and staff interview, the facility failed to ensure 1 of 1 closed record (Resident #1) remained free from a chemical restraint (morphine sulfate-an opioid pain medication). Failure to attempt non-pharmacological interventions and/or utilize the least restrictive alternative medication does not allow the resident to attain and/or maintain his/her highest level of practicable well-being. Findings include: The facility failed to provide a policy on pain management or opioid use when requested. Review of Resident #1's medical record occurred on 01/28/25. Diagnoses included Alzheimer's disease, obsessive compulsive disorder, and dementia with agitation. The current care plan stated, . [Resident #1] has behaviors e/b [evidenced by] verbal taunting, seeks out others, has been physically aggressive at times r/t [related to] Dementia and cognitive decline . Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation 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 2 of 4 reporting periods. 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. Review of the PBJ Data Staff Report CASPER Report 1705D FY (fiscal year) Quarter 4 (July 1 - September 30, 2023) and Quarter 1 (October 1 - December 31, 2023) occurred on 03/18/23, stated, . Failed to Submit Data for the Quarter. Triggered. During an…

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 and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the resident's current status for 3 of 14 sampled residents (Resident #13, #25, and #32). Failure to revise the care plan for Residents #13 and #32 limited the staff's ability to communicate care needs and ensure continuity of care for each resident and failure to update Resident #25's transfer status placed the resident at risk for injury. Findings include: The facility failed to provide a care plan policy. - Review of Resident #13's medical record occurred on all days of survey. The care plan stated, . TOILET USE: Requires assist of 1 staff with mechanical stand lift for toileting. TRANSFER: The resident requires assist of 1 staff w/ [with] mechanical stand lift . A physician's order, dated 01/04/24, stated, Resident will transfer using mechanical stand lift with assist of 1 and gluteal [buttock] strap. Observation on 03/19/24 at 9:59 a.m. showed two certified nurse aides (CNAs) (#7 and #9) assisted Resident #13 with toileting. 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, and resident and staff interview, the facility failed to provide care and services for 1 of 1 sampled residents (Resident #25) reviewed for edema (fluid retention) and 1 of 2 sampled residents (Resident #26) observed wearing a splint. Failure to apply compression stockings as ordered may result in worsening edema and failure to obtain an order for use of a splint may result in worsening pain. Findings include: - Review of Resident #25's medical record occurred on all days of survey. A physician's order, dated 08/30/23, stated, Compression stockings to be utilized for edema management. A physicians note, dated 02/20/24, stated, . bilateral lower extremity edema. Chronic. Continue with compressions [stockings] as directed. The care plan stated, . Staff to apply compression stockings to BLE [bilateral lower extremities] for edema management . Observations of Resident #25 showed the following: * On 03/19/24 at 03:26 p.m., wearing non compression stockings. The resident reported she has those socks [compression stockings] but not sure if I have them…

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, facility policy, and staff interviews, the facility failed to provide supervision and assistive devices necessary to prevent accidents for 2 of 14 sampled residents (Residents #13 and #19). Failure to provide supervision of certified nurse aides (CNAs) by a licensed nurse regarding resident transfer modes and failure to utilize safe/proper technique during transfers may result in unnecessary pain, falls and/or injury for residents. Findings included: Review of the North Dakota Administration Code (NDAC) online at www.ndlegis.gov/information/acdata/pdf/33-43-01.pdf stated, . 33-43-01-12. Supervision and delegation of nursing interventions. An individual on the department's nurse aide registry [CNA] may perform nursing interventions which have been delegated by a licensed nurse. An individual on the departments's nurse aide registry as delegated and supervised by a licensed nurse . Review of the facility policy titled STANDING LIFT occurred on 03/21/24. This policy, dated December 2017, stated, . The knee rest has…

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 a professional reference, and staff interview, the facility failed to provide appropriate toileting for 2 of 12 sampled residents (Resident #8 and #13) who required staff assistance with toileting. Failure to provide toileting may result in a loss of dignity and placed residents at risk for skin breakdown, poor grooming/hygiene, decreased self-esteem, urinary tract infections, and risk for fall and/or injuries. Findings include: The facility failed to provide a policy related to toileting of residents. Kozier & Erb's Fundamentals of Nursing: Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 892, stated, Fecal and Urinary Incontinence: Moisture from incontinence promotes skin maceration [tissue softened by prolonged wetting or soaking] and makes the epidermis more easily eroded and susceptible to injury. Digestive enzymes in feces, urea in urine . also contribute to skin excoriation [area of loss of the superficial layers of the skin .]. Any accumulation of secretions . is irritating to 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 ensure safe and secure storage of medications in 1 of 1 medication carts. Failure to store all medications securely may result in unauthorized access to medications. Findings include: Review of the facility policy titled Medication Administration occurred on 03/20/24. This policy, revised 2016, stated, . The medication cart should be locked when left unattended . Medications should not be left on top of the medication cart . if the nurse or CMA [certified medication aide] is in a resident room and the medication cart is not locked . it has to be in an area where the nurse or CMA can see it . Observation on 03/19/24 at 11:47 a.m., showed a staff nurse (#8) left the medication cart unattended for over eight minutes with six insulin pens/vials on top of the medication cart. The medication cart remained unlocked in the hallway and out of view of the nurse. During an interview, on 03/20/24, an administrative nurse (#5) confirmed she expected staff to ensure medications are secured within 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, facility policy review, and staff interview, the facility failed to ensure staff followed standard infection control practices for 2 of 10 sampled residents (Resident #6 and #16) and 1 supplemental resident (Resident#1). Failure to follow infection control practices related to hand hygiene and glove use has the potential for transmission of communicable diseases and infections to residents and staff. Findings include: Review of the facility policy, Handwashing Specifics occurred on 3/21/24. This policy, revised January 2015, stated, . Handwashing decreases contamination of the hands and prevents spread of pathogens . personnel who perform procedures on residents . should wear gloves . even though gloves are worn, hands should still be washed . before, between and after all physical contacts with the resident . before and after performing any personal body function . - Observation on 03/18/24 at 10:18 a.m., showed a certified nurse aide (CNA) (#15) performed incontinence cares on Resident #16 while in bed. Without performing hand hygiene, the CNA (#15) donned…

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 investigate and report to the State Survey Agency (SSA) potential incidents of abuse/neglect for 2 of 2 sampled residents (Resident #13 and #29) who experienced injury. Failure to investigate and report allegations of abuse/neglect to the SSA places all residents at risk of potential abuse. Findings include: Review of the facility policy titled ABUSE, NEGLECT, MISTREATMENT, AND MISAPPROPRIATION OF RESIDENT PROPERTY occurred on 03/14/23. This policy, dated June 24, 2018, stated, . It is the facility's responsibilities to prevent not only abuse, but also those practices and omissions that if left unchecked, lead to abuse. Everyone must monitor the resident for possible signs of abuse: like suspicious or unexplained bruising . All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source . must be completed within 24 hours of the initial allegation report. Administration will provide a final written report to the North Dakota Department 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 implement policies and procedures that included additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19 for 2 of 2 unvaccinated staff (Staff A and B). Failure to implement additional precautions for staff who are not fully vaccinated may lead to increased risk of transmission and spread of COVID-19 among patients, staff, and visitors. Findings Include: Review of the policy titled Employee COVID-19 Vaccinations occurred on 03/15/23. This policy, revised 10/15/22, stated, . This policy is developed to ensure that all eligible employees are vaccinated against COVID-19 . will implement additional precautions to mitigate the transmission and spread of COVID-19 for all staff who are not fully vaccinated . They will continue to wear surgical masks, check in when getting to work per recommendations. Review of employee vaccination records identified Staff A and B completed appropriate COVID-19 vaccine…

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.