Baptist Health Care Center

F-F609 is considered past noncompliance. The facility implemented corrective actions as follows:

* An email was sent to all facility staff on 11/05/24 defining abuse and to report any form of abust the the manager and the SSA within 24 hours.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 4 355058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 355058 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Baptist Health & Rehab 3400 Nebraska Drive Bismarck, ND 58503

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 * On 11/08/24, education related to abuse was assigned to all facility staff to be completed within one week.

Level of Harm - Minimal harm or *Additionally, the facility directors and team leads were required to print off the email sent on 11/05/24, along potential for actual harm with the definition of abuse and reporting guidelines, and have staff sign and acknowledge when they completed the education. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 4 355058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 355058 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Baptist Health & Rehab 3400 Nebraska Drive Bismarck, ND 58503

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31725 Residents Affected - Few Based on observation, record review, review of the facility reported incident, review of the facility policy, and staff interview, the facility failed to ensure a resident received adequate supervision and assistive devices to prevent accidents for 1 of 1 sampled resident (Resident #1) investigated for a fall. Failure to ensure staff used a mechanical lift properly and verified proper installation of attachments to the Broda chair (specialized wheelchair) resulted in a fall from the mechanical lift.

Finding include:

Review of the facility policy titled Floor based, Full Body Sling Lift use occurred on 01/23/25. This policy, dated 10/27/21, stated, . Transfer resident from chair to bed . Push the UP button on the hand control for the lift until there is slight tension on the sling loops. PERFORM SAFETY CHECK i. Once there is tension on the loops, double check each loop to be sure each is securely in the hook. ii. Double-check the position and stability of all straps and other equipment. v. Lift the resident about 2 inches off the surface and verify that weight is evenly spread between the straps of the sling. vi. Verify the resident will not slide out of the sling or tip backward or forward.

Review of the facility reported incident, stated, . At approximately 1815 [6:15 p.m.] on 1/4/25, a resident, [Resident #1], was involved in a witnessed fall during a transfer with a full body lift. The nurse on duty was promptly notified and called to the resident's room. The CNAs [certified nurse aides] involved in the incident [CNA names], explained that they were transferring the resident from a broda wheelchair to the bed using a full body lift per the residents [sic] care plan. During the transfer, the residents [sic] sling became caught on part of the wheelchair. In an attempt to free the sling, the CNA moved the resident's wheelchair, causing the lift to become unbalanced. As a result, the lift struck the CNA in the head, and a portion of the lift subsequently made contact with the residents [sic] face. This impact caused a skin tear above the resident's right eye and on the bridge of his nose. The lift then tipped over on its left side and fell on to the floor causing

the resident to fall from a height of about 3 feet onto his bottom while still in the sling. The resident reported no pain, aside from discomfort related to the skin tear. A raised area potentially a hematoma was noted to residents [sic] back.

Resident #1's nursing progress notes stated the following:

* 01/04/25 at 8:10 p.m. After further assessment this nurse found a lump on the resident's

right lower back, upon palpation resident said bump was painful. No redness or bruising was found at this time and bump was blanchable. Family was called and updated and consented to sending in. This nurse called on call to get order to send resident in for further assessment. Metro ambulance arrived about 2100 [9:00 p.m.] .

* 01/05/25 at 3:15 p.m. This nurse spoke with resident's wife, [name]. Per [wife's name], the sutures above resident's right eye are dissolvable.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 4 355058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 355058 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Baptist Health & Rehab 3400 Nebraska Drive Bismarck, ND 58503

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 An email from the facility's purchasing employee, dated 01/14/25, stated, [Staff member name] and I met and looked at chair [Resident #1's Broda chair]. I found the handles at the end of arm rest were placed upside Level of Harm - Actual harm down which could have been where the sling got caught, but I'm not sure. I adjusted them to the proper placement. Residents Affected - Few

An Occupational therapist note, dated 12/09/24 at 5:02 p.m., stated, Review of broda chair . Resident continues using the broda chair for comfort per family request. (The therapist failed to mention the handles at

the end of the arm rests.)

During an interview on the afternoon of 01/23/25 while observing Resident #1's Broda chair an administrative nurse (#1) explained that the handles on the resident's Broda chair were turned downwards and therefore

the sling could have easily been caught on these handles. This staff member was unsure how long the handles had been on the Broda chair and if the resident utilized the handles.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 4 355058