McKenzie County Healthcare Systems Long Term Care

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 4 of 5 sampled residents (Resident #1, #7, #15, and #28) observed during cares. Failure to practice infection control standards related to hand hygiene and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 07/24/25. This policy, dated June 2023, stated, . The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of the facility policy titled Enhanced Barrier Precautions occurred on 07/24/25. This policy, dated April 2024, stated, . infection control intervention designed to reduce transmission of multidrug-resistant organism that employs targeted gown and glove use during high contact resident care activities. HAND HYGIENE - Observation on 07/21/25 at 4:15 p.m. showed an enhanced…

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 a resident for self-administration of medications for 1 of 1 sampled resident (Resident #5) observed with medications at the bedside. Failure to evaluate the ability for residents to safely self-administer medications may result in medication errors and/or harm to the resident.Findings include: Review of the facility policy Self Administration of Medication occurred on 07/24/24. This policy, dated June 2024, stated, .resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Observations on all days of survey showed an unlabeled bottle of Calm Forte (sleep aid) on the top of a bedside shelf in Resident #5's room. Review of Resident #5's medical record occurred on all days of survey. The record lacked an assessment and a physician's order for Resident #5 to self-administer medications and lacked orders for the medication Calm Forte. During an interview on 07/23/25 at 10:13…

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 residents remained free from unnecessary psychotropic medications for 1 of 1 sampled resident (Resident #22) who received an as needed (PRN) psychotropic. Failure to limit PRN psychotropic use to 14 days unless reevaluated by a practitioner placed the resident at risk of receiving unnecessary medications, experiencing adverse drug effects, and possible chemical restraint. Findings include:Review of the facility policy titled Use of Psychotropic Medications occurred on 07/24/25. This policy, dated 06/27/24, stated, . A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: . anti-anxiety . PRN orders for all psychotropic drugs shall be used only when the medication is necessary . and for a limited duration . If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall…

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 provide respiratory care consistent with professional standards of practice for 1 of 1 sampled resident (Resident #15) receiving oxygen by nasal cannula. Failure to obtain a physician's order to administer oxygen may result in complications and compromise the residents' respiratory status.Findings include: Review of the facility policy titled Oxygene [sic] Administration occurred on 07/24/25. This policy, dated 06/01/19, stated, . Procedure: . Check physician's orders for liter flow and method of administration . Observation on all days of survey showed Resident #15 with continuous oxygen (O2) in place via a nasal cannula at 2 liters (L). Review of Resident #15's medical record occurred on all days of survey. Diagnoses included chronic obstructive pulmonary disease (COPD). The current care plan stated, . I have a need for oxygen therapy R/T [related to] Respiratory illness, COPD . OXYGEN SETTINGS: I have O2 via nasal prongs/mask @ [at] 2-3L to keep sats [saturations] >92%…

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 5 of 5 sampled residents (Resident #3, #5, #10, #23, and #28) transferred to the hospital. 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 #3, #5, #10, #23, and #28's medical records occurred on all days of survey and identified the following hospital transfers: * Resident #3: 10/27/23 and 05/07/24. * Resident #5: 08/04/23. * Resident #10: 04/05/24 and 04/26/24. * Resident #23: 05/03/24. * Resident #28: 04/29/24. The above residents' medical records lacked evidence the facility provided the resident and/or representative with a written transfer notice. During an interview on 06/18/24 at 2:13 p.m., an administrative staff member (#1) stated the facility does not have a Hospital Transfer policy. During an interview on 06/18/24 at 5:15 p.m., an administrative staff member (#1)…

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 provide a bed hold notice upon transfer to the hospital for 5 of 5 sampled residents (Resident #3, #5, #10, #23, and #28) transferred to the hospital. Failure to provide a bed hold notice does not allow residents or their legal representatives to make informed choices regarding their readmission rights. Findings include: Review of the facility policy titled Bed Hold occurred on 06/19/24. This policy, dated 04/17/24, stated, It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold policies prior to transferring a resident to the hospital . Review of Resident #3, #5, #10, #23, and #28's medical records occurred on all days of survey and identified the following hospital transfers: * Resident #3: 10/27/23 and 05/07/24. * Resident #5: 08/04/23. * Resident #10: 04/05/24 and 04/26/24. * Resident #23: 05/03/24. * Resident #28: 04/29/24. The above residents' medical records lacked evidence the facility provided 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy, and staff interview, the facility failed to review and revise the care plan for 1 of 12 sampled residents (Resident #3). Failure to review and revise the care plan limited staff's ability to communicate needs, ensure continuity of care, and may negatively impact the care provided to the resident. Findings include: Review of the facility policy titled Comprehensive Care Plans occurred on 06/19/24. This policy, dated 11/08/22, stated, . The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS [Minimum Data Set] assessment. Review of Resident #3's medical record occurred on all days of survey. A progress note, dated 04/07/24 at 11:04 a m., stated, Foley Cath [catheter] removed at 5 a.m. A quarterly MDS, dated [DATE], identified no Foley catheter, maximum assist required for transfers, not toileted, and no ambulation attempted. The current care plan identified Resident #3 had a Foley catheter…

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 staff interview, the facility failed to ensure 1 of 1 dietary manager (#1) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure staff have the qualifications to carry out the functions of food and nutrition services has the potential to result in foodborne illness to residents, staff, and visitors. Findings include: During an interview on 07/17/23 at 12:00 p.m., the dietary manager (#1) confirmed he has not completed the necessary courses required for the director of food and nutrition services. The facility failed to ensure the dietary manager (#1) completed the required education for a certified dietary manager, certified food service manager, or a national certification for food service management and safety from a national certifying body

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy, review of a professional reference, and staff interview, the facility failed to provide adequate supervision and assistive devices necessary to prevent accidents for 2 of 2 sampled residents (Resident #12 and #18) and 2 supplemental residents (#4 and #21) observed during a gait belt transfer. Failure to properly use a gait belt during transfers placed the resident at risk of accidents and injury. Findings include: Review of the facility policy Use of Gait Belt occurred on 07/19/23. This policy, dated October 2022, stated, . To prevent accidents . use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety . [NAME], [NAME], and Frandsen, Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 10th edition, Pearson Education, Inc., New Jersey, page 1054, stated, . If the client is a low safety risk . use a gait/transfer belt for standby assist as needed and assistive devices as needed . and 1-2 caregivers.…

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 for 3 of 3 sampled residents (Resident #12, #13 and #32) and 1 supplemental resident (#30) with orders for enhanced barrier precautions (EBP), and 2 of 12 sampled residents (Residents #1 and #15) observed during cares. Failure to practice infection control standards related to use of personal protective equipment (PPE) 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 07/19/23. This undated policy, stated, . Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO [multi drug resistant organism] as well as those at risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Clear signage will be posted outside of the resident room indicating the type of precautions…

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 comprehensive care plans to reflect the current status for 1 of 12 sampled residents (Resident #32). 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 Care Plan Revisions occurred on 07/19/23. This policy, dated September 2022, stated, . the comprehensive care plan will be reviewed, and revised as necessary . the care plan will be updated with new or modified interventions . - Review of Resident #32's medical record occurred on all days of survey. A Physician's order, dated 06/22/23, stated, . foley catheter required for obstructive uropathy due to urinary retention. and included an order for Enhanced Barrier Precautions (EBP) (per CDC [centers for disease control and prevention]) related to medical device (indwelling catheter). The current care plan lacked goals and interventions related to Resident #32's indwelling catheter and EBP.…

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.