St Vincent's - A Prospera Community

F-F689 is considered past non-compliance. The facility implemented corrective actions for other residents who may be affected by the deficient practice as follows:

* Completed an investigation into Resident #243's fall,

* Updated the care plan for all residents with anti-rollback wheelchairs,

* Re-education and competency evaluations provided to all facility drivers regarding anti-rollback wheelchairs

on 10/11/24, and

* Implemented audits on van transfers.

52000

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 31 355060 Department of Health & Human Services Printed: 08/31/2025 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 355060 B. Wing 04/03/2025

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

St Vincent's - A Prospera Community 1021 N 26th St Bismarck, ND 58501

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 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm 27221

Residents Affected - Some Based on observation, record review, review of facility policy, review of facility assessment, review of resident council meeting minutes, review of call light logs, review of staffing schedule, confidential resident and family interviews, and staff interviews, the facility failed to ensure sufficient nursing staff and related services are available at all times to meet the residents' needs for 2 of 23 sampled residents (Resident #243 and #293) and 11 confidential residents (Resident A, B, C, D, E, F, G, H, I, J, and K) who required staff assistance. Failure to provide sufficient staffing does not promote each resident's rights, physical, mental, and psychosocial well-being, and/or provide a safe environment for the residents.

Findings include:

Review of the facility assessment occurred on 04/03/25. The assessment stated, . [Facility] utilizes an interdisciplinary approach to meet the needs of our population and its individuals across all shift [sic] including nights and weekends . As the needs of the population change as indicated by the number of residents served, acuity levels, MDS [Minimum Data Set] results and care plans the staffing pattern is adjusted to meet those needs. We consider variability in care needs across day, evening, and night shifts, including weekends and holidays, and adjust as necessary. We confirm needs are met by engaging in frequent communication with residents, their families and representatives with regular care conferences, rounding, quality assurance audits, resident group meetings, availability of suggestion/concern forms and email surveys.

Review of the facility policy titled Call Light occurred on 04/02/25. This policy, revised 07/29/24, stated, When resident's call light is observed/heard, go to the resident's room promptly.

Review of the resident council meeting minutes, dated November 2024-February 2025, identified the following resident concerns:

* Call light was on for long periods of time.

* Call light was on for 30 minutes to a hour.

The Resident Council met on 03/31/25 at 1:20 p.m. The residents voiced the following concerns during the meeting:

* Resident F stated he/she has waited 30 minutes for his/her call light to be answered. He/she also reported activities are often delayed and/or cut short due to a lack of staff.

* Resident G stated he/she has waited 30 minutes for his/her call light to be answered, especially at 8:00 a.m. , 2:00 p.m., or 10:00 p.m.

* Resident H stated he/she has waited over 30 minutes for his/her call light to be answered, and has experienced pain/discomfort waiting to go to the bathroom. He/she also reported the activities department was short staffed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 31 355060 Department of Health & Human Services Printed: 08/31/2025 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 355060 B. Wing 04/03/2025

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

St Vincent's - A Prospera Community 1021 N 26th St Bismarck, ND 58501

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 0725 Confidential resident and family interviews identified the following:

Level of Harm - Minimal harm or * 03/31/25 Resident A stated, call lights were not answered around shift change, certified nurse aides potential for actual harm (CNAs) seem rushed, and he/she has been left in the bathroom for long periods of time.

Residents Affected - Some * 03/31/25 Resident B stated, staff are so busy and rushed in the evening and after 10:00 p.m., they don't always check on me during the night.

* 03/31/25 Resident C stated, he/she has waited 30-40 minutes at times for the call light to be answered. Stated, it is worse around 3:00 p.m. Sometimes they forget about me, they forget my breakfast and lunch and then they bring it to me late. Resident C stated one time they forgot to give me the call light (Resident not able to access call light on his/her own) and I was without it from 10:00 p.m. until 3:00 a.m. and then I started yelling and they came. Resident C stated there have been a few other times staff have forgotten to place the call light and he/she has just had to wait for a staff member to come. The resident stated he/she has tried calling the nurses' station, but not able to get through.

* 03/31/25 Resident D stated, staff are so busy in the evening, I have to wait about 1/2 hour for my call light to be answered.

* 03/31/25 Resident E stated, one time they came in and turned off the call light and said someone would be right in, but then they didn't come back for an hour.

* 03/31/25 Resident J stated, I had to wait one hour for help to the bathroom. I can't hold it that long. Review of the call light log confirmed a wait time of 59 minutes on 03/30/25.

* 03/31/25 Resident K stated, The aide [CNA] told me to press the light when I was done on the toilet. I kept calling and calling and she never came back.

* 03/31/25 Family Member #1 stated when she called on the phone, she could not get ahold of the nurse's station, the call light was not always placed in reach of the resident, oral cares were not completed, and the resident was not dressed/toileted timely for appointments.

* 03/31/25 Family Member #2 stated the facility is short of staff on weekends and evenings and there is not enough staff to assist residents who need help with eating

* 04/01/25 When asked about staff's response time after the call light is activated, Resident I stated, I have to wait 30 to 45 minutes, and staff are rushed and short, not enough help.

Review of the call light logs from 03/26/25 to 04/01/25 showed the following:

* Resident C waited 22 minutes or greater on 14 occasions, with the longest time being 51 minutes.

* Resident D waited 20 minutes or greater on ten occasions, with the longest time being 33 minutes.

- Review of Resident #243's medical record occurred on all days of survey. The progress notes identified the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 31 355060 Department of Health & Human Services Printed: 08/31/2025 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 355060 B. Wing 04/03/2025

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

St Vincent's - A Prospera Community 1021 N 26th St Bismarck, ND 58501

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 0725 * 01/26/25 at 3:21 p.m., resident was yelling, swearing at staff in the AM, upset about PM shift the previous night. Upset about having to wait for his call light to be answered at bedtime. Level of Harm - Minimal harm or potential for actual harm * 02/01/25 at 5:46 a.m., Resident slept till 0330 [3:30] am he stated he put on his light and was waiting to long for the cna. Nurse was notified by cna that resident called the police to help him, police had asked if Residents Affected - Some resident was safe and the cna stated he is sitting in his wheelchair at the nurses table. Police officers left facility at that time .

- Review of Resident #293's medical record occurred on all days of survey. The care plan stated, . TOILET USE: Resident requires check and change. Resident can be unaware of when he is wet/soiled. BRIEF USE: Resident uses incontinence products for heavy incontinence. Check every 2-3 hours and prn [as needed].

Observations of Resident #293 on 03/31/25 showed the following:

* At 2:12 p.m., seated in a wheelchair in the activity room, attempted to self-propel, and stated, I have to go, let me go. A CNA (#11) told the resident to stay there and sit down.

* At 3:50 p.m., seated in a wheelchair stated, I have to go. The resident attempted to self-propel the wheelchair down the hallway and two CNAs (#11 and #12) told the resident to stay there and did not assist

the resident to the bathroom.

* At 4:21 p.m., showed urine ran down the wheelchair and on to the floor in the activity room.

Review of Resident #293 toileting documentation for 03/31/25 showed the staff last toileted the resident at 1:33 p.m.

During an interview on 03/31/25 at 5:18 p.m., an administrative nurse (#10) stated he expected staff to toilet residents as care planned and as needed.

On 03/31/25 at 3:36 p.m. and 5:00 p.m., staff interviews identified the following:

* A nurse (#21) reported being responsible for 37 to 57 residents during each shift. She also indicated there are days she is not able to complete all her assigned duties during the shift.

* An administrative staff member (#22) reported staffing is based on the census, and stated weekends are staffed the same as weekdays, except for baths. Residents are bathed Monday-Friday.

During an interview on 04/03/25 at 8:38 a.m. an administrative staff member (#1) stated she expected call light wait times under 15 minutes or under 20 minutes during mealtimes.

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39685

52000

51999

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 31 355060 Department of Health & Human Services Printed: 08/31/2025 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 355060 B. Wing 04/03/2025

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

St Vincent's - A Prospera Community 1021 N 26th St Bismarck, ND 58501

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 0732 Post nurse staffing information every day.

Level of Harm - Potential for 27221 minimal harm Based on observation and review of facility policy, the facility failed to ensure posting of accurate staffing Residents Affected - Many information on 2 of 4 days of survey (March 31 and April 2, 2025). Failure to post accurate staffing data does not allow residents and visitors to be aware of the number of licensed and unlicensed staff on duty each shift.

Findings include:

Review of the facility policy titled Nursing Staff Daily Posting Requirements occurred on 04/03/25. This policy, revised on 12/02/24, stated, . skilled care locations will post daily the staffing and resident census at

the beginning of each shift and update as appropriate .

Observation of the daily staffing report occurred on all days of survey as follows:

* 03/31/25 at 3:50 p.m., the date of the report showed 03/29/25.

* 04/02/25 at 10:25 a.m., the date of the report showed 04/03/25.

The facility failed to ensure staffing information was posted on the correct day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 31 355060 Department of Health & Human Services Printed: 08/31/2025 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 355060 B. Wing 04/03/2025

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

St Vincent's - A Prospera Community 1021 N 26th St Bismarck, ND 58501

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 39685 Residents Affected - Few Based on observation, facility policy, record review and staff interview the facility failed to ensure accurate reconciliation and storage of medications for 1 of 2 sampled residents (Resident #68) observed during medication pass. Failure to reconcile and dispose of medications may result in medications errors and the potential for drug diversion.

Findings include:

Review of the facility policy titled, Medications: Acquisition Receiving Dispensing Storage occurred on 04/03/25. This policy, dated 03/04/25, stated, .Controlled: . To provide verification and reconciliation of all controlled medications . For all schedule II-controlled medications . the nurse/going off shift unlocks the controlled medication storage unit and then will go to the narcotic count book and read each controlled substance to the on-coming nurse . the on-coming nurse will verify the physical medication count matches

the remaining amount listed in the controlled substance book for each medication . the on-coming nurse will physically examine the containers/packages of each controlled medication for evidence of tampering (opened packages) . should evidence of tampering be present, an incident report should be completed and

the director of nursing notified immediately . if the physical count is NOT in agreement with the controlled substance book, the error must be completed prior to the end of shift and reported to the director of nursing

before staff administering medications for the shift leave the building .

Review of Resident #68's medical record occurred on all days of survey. The current physician orders included Morphine Sulfate Concentrate 20 mg/ml (milligrams per milliliter). Give 0.25 ml oral four times a day for pain and 0.25 ml every hour as needed.

Observation on 04/02/25 at 8:40 a.m., showed a staff nurse (#23) opened the medication cart, obtained Resident #68's empty morphine sulfate bottle. Review of the narcotic count sheet showed 4.25 ml of morphine sulfate remained in the bottle.

During an interview on the afternoon of 04/02/25, an administrative nurse (#2) stated she expected staff to reconcile and report discrepancies with narcotic medications immediately to nursing management per facility policy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 31 355060 Department of Health & Human Services Printed: 08/31/2025 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 355060 B. Wing 04/03/2025

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

St Vincent's - A Prospera Community 1021 N 26th St Bismarck, ND 58501

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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 19410 potential for actual harm Based on observation, review of facility policy, test tray, and resident interviews, the facility failed to serve Residents Affected - Many foods at palatable temperatures in 3 of 3 units ([NAME] Place, Sacred Heart Place, and [NAME] Place). Failure to serve food at a temperature that is acceptable and palatable to residents' places residents at risk of decreased intake, weight loss, and nutritional decline.

Findings include:

Review of the facility policy titled Dining Service Standards occurred on 04/03/25. This policy, dated 06/13/24, stated, . Definitions: Food Distribution - the process of getting food to the resident. This may include holding hot foods in a steam table or cold foods under refrigeration for temperature control, dispensing food portions for individual residents, and dining services including service to resident room. Meals assembled in the kitchen and delivered to residents' rooms or dining area must be covered individually or in a mobile food cart. PURPOSE: To provide an overview of desired expectations for a pleasant and positive dining experience . POLICY: . Residents will be provided meals that are nourishing, attractive, and palatable and are served at . appetizing temperature.

Review of the facility policy titled Food Temperature Monitoring - Food and Nutrition Services occurred on 04/03/25. This policy, dated 12/16/24, stated, . Definitions: . Proper serving temperature - A temperature that is appetizing to the resident . this is the temperature when the food reaches the resident. Procedure: . Test tray monitoring occurs as a part of quality assurance monitoring to ensure temperatures are acceptable when the location uses room trays or satellite dining rooms. Temperatures for test trays are based on proper serving temperature, not tray line holding temperatures based on food safety. Test tray is checked after all residents have been served.

Sacred Heart Place and Emmanual Place Resident Interviews and Observations:

- Observation on 03/31/25 at 11:40 a.m. showed Resident #393 in his room eating lunch. The resident stated, The food is always cold.

- During an interview on 03/31/25 at 11:58 a.m., Resident #44 stated the hot food is not always hot, she always eats in her room, and the toast is always cold because they make it ahead of time.

-During an interview on 03/31/25 at 12:17 p.m., Resident #33 stated he always eats in his room for the evening meal and the food is not hot.

- During an interview on 03/31/25 at 12:25 p.m., Resident #40 stated most of the time the food is cold, as I get my tray late.

- Observation on 04/01/25 at 8:40 a.m., showed Resident #38 laying in bed with his breakfast tray at the bedside. The resident stated, I'm waiting to eat. She [the CNA assisting him] went to go make me some toast that is warm.

- During an interview on 04/01/25 at 10:14 a.m., Resident #8 stated, Dining room food is cold when served.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 31 355060 Department of Health & Human Services Printed: 08/31/2025 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 355060 B. Wing 04/03/2025

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

St Vincent's - A Prospera Community 1021 N 26th St Bismarck, ND 58501

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 0804 - Observation on 04/01/25 at 11:20 a.m. showed Resident #393 assisted to the dining room by a CNA. The resident stated, I'm going to the dining room because when I get my food in my room it is ice cold. Level of Harm - Minimal harm or potential for actual harm - During an interview on 04/01/25, at 11:58, Resident #44 stated, the food is not hot

Residents Affected - Many - During an interview on 04/01/25 at 12:05 p.m., Resident #11 stated she ate in the dining room today and

the temperature of the food was hot, but when she eats in her room by the time it gets to me it is cool.

[NAME] Place Test Tray:

Upon request, the kitchen staff sent a meal test tray in a cart to [NAME] Place. The cart arrived at 11:52 a.m.

A staff member took the last tray out of the cart at 12:15 p.m. and delivered it to a resident. The surveyor took the test tray out at the same time, brought it to the conference room, and checked the temperatures of each food item. Temperatures were as follows: Chicken 104.8 degrees Fahrenheit (F), Zucchini 98 degrees F, Pasta 94 degrees F. The surveyors tasted the meal, and all confirmed the food was lukewarm, not hot.

51999

52000

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 31 355060 Department of Health & Human Services Printed: 08/31/2025 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 355060 B. Wing 04/03/2025

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

St Vincent's - A Prospera Community 1021 N 26th St Bismarck, ND 58501

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 19410

Residents Affected - Many Based on observation, review of professional reference, and staff interview, the facility failed to maintain cold storage areas and kitchen equipment in a sanitary manner for 1 of 1 kitchen. Failure to clean fans, ceilings, walls in areas where food is stored and failure to ensure a cleanable surface for kitchen equipment has the potential for contamination of food and may result in a foodborne illness.

Findings Include:

The 2022 Food and Drug Administration (FDA) Food Code, Chapter 3 Food, Section 3-305 Preventing Contamination From the Premises, Section 3-305.11 states, A. Food shall be protected from contamination by storing the food: . 2) Where it is not exposed to . dust, or other contamination.

The 2022 Food and Drug Administration (FDA) Food Code, Annex 3, Chapter 4 Equipment, . Section 4-101. 11 Characteristics . equipment is subject to deterioration because of its nature, i.e., intended use over an extended period of time. Surfaces that are unable to be routinely cleaned and sanitized because of the materials used could harbor foodborne pathogens . Inability to effectively wash, rinse and sanitize the surfaces of food equipment may lead to the buildup of pathogenic organisms transmissible through food.

The initial observation of the kitchen occurred on 03/31/25 at 11:40 a.m.m The final observation of the kitchen occurred on 04/03/25 at 12:00 p.m. with an administrative dietary staff member (#9). Observation on both days showed the following:

* Walk in Cooler - accumulation of thick, dark black dust/dirt on the fan and accumulation of dust on the ceiling/wall around two separate condenser fans.

* Walk in Freezer - accumulation of dark black dust/dirt on the fan and accumulation of dust on the wall/ceiling around the condenser fan.

* Oven - handles of one reach-in oven covered with peeling/tattered duct tape, making it a non-cleanable surface.

During an interview on 04/03/25 at 1:00 p.m., the administrative dietary staff member (#9) confirmed the presence of peeling/tattered duct tape on the oven doors and confirmed he expected staff to clean the black dust/dirt from the fans, walls, and ceilings in the walk-in cooler and freezer.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 31 355060 Department of Health & Human Services Printed: 08/31/2025 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 355060 B. Wing 04/03/2025

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

St Vincent's - A Prospera Community 1021 N 26th St Bismarck, ND 58501

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 0865 Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or 27221 potential for actual harm Based on review of the State Agency (SA) facility files, survey findings, review of facility policy, and staff Residents Affected - Many interview, the facility failed to develop a Quality Assurance and Performance Improvement (QAPI) process to evaluate and identify problems and opportunities to improve services/outcomes, decrease or prevent likelihood of problems or occurrence of adverse events, and ensure compliance with federal requirements.

Findings include:

Review of the facility policy titled Quality Assurance and Performance Improvement - QAPI occurred on 04/03/25. This policy, revised on 10/09/23, stated, . The QAPI program uses data to monitor the effectiveness and safety of services and quality of care; identify and prioritize problems and process improvement opportunities and takes action to address areas in need of improvement. Performance Improvement project activity will be monitored for progress and sustainability by the location.

Review of the state agency files indicated the facility failed to maintain compliance at

F-F812 Store, Prepare, and Serve Food in Sanitary Manor

*

F-F880 Infection Control

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 31 355060 Department of Health & Human Services Printed: 08/31/2025 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 355060 B. Wing 04/03/2025

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

St Vincent's - A Prospera Community 1021 N 26th St Bismarck, ND 58501

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 19410 potential for actual harm Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow Residents Affected - Few standards of infection control and prevention for 1 of 5 sampled residents (Resident #78) in Enhanced Barrier Precautions (EBP) and 1 of 4 sampled residents (Resident #25) who required staff assistance with perineal care. Failure to practice infection control standards related to EBP, urinary catheter care, and perineal care has the potential to spread infection throughout the facility.

Findings include:

Review of the facility policy, Standard and Transmission-Based Precautions occurred on 04/03/25. This policy, dated, 04/02/24, stated, Purpose: . To prevent the spread of infection . Enhanced Barrier Precautions (EBP): Enhanced barrier precautions expand the use of PPE [personal protective equipment] beyond situations in which exposure to . body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities . Enhanced Barrier Precautions are needed for residents with . Indwelling Medical devices (. indwelling urinary catheters). High-Contact Resident Care Activities include: . device care or use (. urinary catheter).

Review of the facility policy titled Perineal Care occurred on 04/03/25. This policy, revised 07/29/24, stated, . using gentle downward strokes from the front to the back of the perineum .

- Review of Resident #78's medical record occurred on all days of survey. The care plan stated, . The resident requires Enhanced Barrier Precautions (EBP) R/T [related to]: foley catheter. Instruct staff to wear disposable gloves and gown when performing high contact resident care activities .

Observation on 04/02/25 at 11:11 a.m. showed Resident #78's room with signage for EBP on the door and a supply cart located at the entrance of the room. The certified nurse aide (CNA) (#4) entered the room to empty the resident's urinary drainage bag. The CNA applied gloves, failed to apply a gown, cleaned the end of catheter tubing with an alcohol swab, emptied urine into a collection container, then emptied the urine into

the toilet. The CNA (#4) failed to apply a gown when providing high-contact care (emptying a urinary drainage bag) for Resident #78.

- Review of Resident #25's medical record occurred on all days of survey. Diagnoses include acute cystitis without hematuria (bladder inflammation without blood in urine) and a history of urinary tract infections. The quarterly Minimum Data Set (MDS), dated [DATE REDACTED], identified occasionally incontinent of urine and a UTI within the last 30 days.

Review of Resident #25's laboratory values over the past six months showed positive urine cultures in November 2024, February 2025, and March 2025 (indicating UTIs). The resident was hospitalized from February 14-18, 2025 related to a UTI requiring IV (intravenous) antibiotics.

The current care plan stated, . at risk for bladder infections R/T [related to] HX [history] of UTI . Monitor/document for s/s [signs and symptoms] UTI . TOILET USE: . Wears a liner in her own undergarments. Peri [perineal] care assist of 1 .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 31 355060 Department of Health & Human Services Printed: 08/31/2025 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 355060 B. Wing 04/03/2025

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

St Vincent's - A Prospera Community 1021 N 26th St Bismarck, ND 58501

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 0880 Observations of Resident #25 on 04/01/25 showed the following:

Level of Harm - Minimal harm or * At 8:05 a.m., A certified nursing assistant (CNA) (#3) assisted Resident #25 to the toilet. Resident #25 wore potential for actual harm two briefs and a liner and stated it was hard to sleep and uncomfortable. The CNA (#3) took a washcloth from the basin filled with soapy water and wiped Resident #25's perineal area from back to front and then Residents Affected - Few wiped back to front.

During an interview on 04/01/25 at 8:05 a.m. the CNA (#3) confirmed staff are not supposed to double brief residents.

During an interview the afternoon of 04/03/25, an administrative staff member (#1) confirmed she expected staff to wear a gown when performing high contact care for a resident in EBP and two administrative staff members (#1 and #2) confirmed perineal cares were not completed correctly.

52000

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 31 355060