St Vincent's - A Prospera Community

Review of the facility policy titled Advanced Care Planning occurred on 04/03/25.

This policy, revised on 12/02/24, stated, .

Purpose: To provide each resident the opportunity to make decisions regarding medical care . assist residents to make their choices known regarding well-being and treatment .

Residents and resident surrogate or proxy decision makers have the right to make decisions concerning medical care, including the right to accept or to refuse medical . treatment.

During an interview on 04/03/25 at 12:24 p.m., an administrative nurse (#2) reported staff conduct care conferences every quarter, after a significant change, and after a hospitalization.

Review of Resident #243's medical record occurred on all days of survey.

The progress notes lacked evidence the facility invited Resident #243 and/or a family representative to care conferences following admission/quarterly assessments on 05/06/24, 10/30/24, and 01/30/25.

Facility staff failed to afford Resident #243 and/or his family representative the opportunity to participate in the care planning process on a quarterly basis and/or after each hospitalization and failed to inform him, in advance, of changes to the plan of care.

355060 04/03/2025

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

During an interview on 04/03/25 at 12:20 p.m., when asked questions regarding the incident that occurred on 01/31/25, an administrative staff member (#1) stated, I didn't know about this. I will be submitting a report today and doing an investigation.

The facility failed to assess and monitor Resident #243's patterns of behavior in an effort to protect other residents from abuse and minimize his aggressive and/or inappropriate behaviors towards other residents.

The facility failed to ensure Resident #243 did not infringe upon the rights of other residents to be free from verbal abuse.

355060 04/03/2025

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

Review of Resident #37's electronic medication administration record (EMAR) from December 18th, 2024, through February 28, 2025, (approximately 73 days), identified staff administered PRN Ativan 50 times.

The nursing progress notes indicated the facility staff administered PRN Ativan due to the resident's restlessness, agitation, rudeness to staff, refusing cares, aggression to the staff, and wanting to leave the facility.

The medical record included the following progress notes: * 01/14/25 at 11:02 a.m., .

Seen by psych, [psychiatry] resident improved. * 01/19/25 at 3:09 p.m., .

Mood and behavior team met for month of December [2024] she comments about going home and becomes restless at times . * 01/30/25 at 2:10 p.m., .

Mood and behavior team met for the month of January [2025] her behaviors have been much. [sic] No new concerns for mood or behavior were noted at this time. * 02/26/25 at 4:43 p.m., .

Mood and behavior team met for the month of February [2025].

There are no concerns with mood or behavior wise noted for the month. * 03/13/25 at 2:34 p.m., .

Behavior team met for month of March [2025].

Resident less anxious and wanting to sleep more.

A physician's progress note dated, 03/04/25, stated, .

Review of MAR does indicate PRN ativan is used often.

Will schedule a bedtime dose in addition to afternoon dose and continue PRN. has PRN Ativan 0.5 mg [milligrams] every 6 hours as needed. MAR indicates that in the last month, she did use ativan 10x [times] with needing it twice on two of those days.

Overall improved and not so problematic .

Failure to assess and implement behavioral and non-pharmacological interventions before utilization of PRN Ativan may have contributed to the resident's increased sleeping, and decreased responsiveness to staff.

355060 04/03/2025

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

going to kick your [blaspheme] you mother [blaspheme].' The other male resident stated 'I'm going

Resident #243 threatened another resident on 01/31/25, an administrative staff member (#1) stated, I didn't know about this.

Facility staff failed to identify Resident #243's explosive outbursts and/or inappropriate behaviors as abusive and failed to report the incident that occurred on 01/31/25 to the administrator and State agency.

355060 04/03/2025

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

During an interview on 04/03/25 at 12:20 p.m., when asked what steps the facility took when Resident #243 threatened another resident on 01/31/25, an administrative staff member (#1) stated, I didn't know about this.

The facility failed to thoroughly investigate the incident that occurred on 01/31/25 between Resident #243 and another resident and the allegations by Resident A, prevent further potential verbal abuse and mistreatment while the investigation is in process, and implement appropriate corrective actions.

355060 04/03/2025

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

Review of the facility policy titled Discharge and Transfer occurred on 04/03/25.

This policy, revised on 03/28/25, stated, .

Before a location transfers or discharges a resident, the location must .

Notify the resident and the resident's representative of the transfer . and the reason for the move in writing .

When a resident is temporarily transferred on an emergency basis to an acute care center, a notice of transfer must be provided to the resident and resident representative as soon as practicable before the transfer.

Copies of notices for emergency transfers must also still be sent to the ombudsman . A location must provide and document sufficient preparation and orientation to residents to ensure safe and orderly . discharge from the location.

Sufficient preparation and orientation means the location informs the resident where he or she is going and takes steps under its control to minimize anxiety and ensure safe transportation. - Review of Resident #78's medical record occurred on all days of survey and identified a hospital transfer on 01/07/25.

The medical record lacked evidence the facility provided the resident and/or representative with a written transfer notice or a copy of the transfer to the ombudsman.

During an interview on 04/02/25, a social service staff member (#17) confirmed the facility did not have a copy of the transfer notice provided to Resident #78 or their representative or to the ombudsman for the hospitalization on 01/07/25. - Review of Resident #243's medical record occurred on all days of survey and identified hospital transfers on 03/30/25. A Notice of Transfer for Hospitalization form, dated 03/30/25, indicated the resident received written notification on 04/01/25, two days after the transfer.

The facility failed to provide Resident #243 with a written notice prior to transferring him to the hospital on [DATE].

355060 04/03/2025

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

Review of Resident #37's medical record occurred on all days of survey. An admission Minimum Data Set (MDS), dated [DATE], identified supervision required with oral hygiene and moderate/partial assistance required with taking on/off socks and shoes. A quarterly MDS, dated [DATE], identified as moderate/partial assistance required with oral hygiene, maximum/substantial assistance required with taking on/off shoes and socks and a weight loss.

The record lacked evidence facility staff identified and/or completed a SCSA following Resident #37's decline in activities of daily living and weight loss.

During an interview on 04/03/25 at 11:16 a.m., an administrative staff nurse (#13) verified Resident #37 declined with oral hygiene, taking on/off shoes and socks, and had a weight loss.

355060 04/03/2025

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

posed a serious threat to other residents and described him as having an explosive temper and

looking for staff, spit on the walls and floor in the family room, and urinated in emesis bags in front of

Resident #243's care plan failed to address his behaviors towards other residents residing in the facility. Resident 243's medical record also showed a diagnosis of diabetes mellitus.

The current physician's orders included 100 units/milliliter Insulin Lispro Injection Solution per sliding scale four times a day for diabetes. Resident #243's care plan failed to address symptoms of diabetes and/or the possible complications that may occur. - Review of Resident #443's medical record occurred on all days of survey.

Diagnoses included quadriplegia and an abdominal wound. A quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #443 is at risk for developing pressure ulcers. Resident #443's care plan lacked a problem, goal, and interventions related to the resident's abdominal wound and high risk for developing pressure ulcers.

355060 04/03/2025

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

Review of Resident #1's medical record occurred on all days of survey and included a diagnoss of type 2 diabetes mellitus. A physician's order, dated 10/10/24 stated, ACCU-CHECKS [blood glucose monitoring] before meals.

Call PCP [Primary Care Provider] if BS [blood sugar] is < [less than] 60 or > [greater than] 400.

Review of Resident #1's Blood Sugar Summary, dated January 1 - March 31, 2025, showed the following blood glucose readings: * 01/24/25 at 12:22 p.m. - 567.0 mg/dL [milligrams per deciliter] * 01/26/25 at 5:21 p.m. - 404.0 mg/dL The medical record lacked documentation the facility notified Resident #1's provider of the elevated blood glucose levels.

During an interview on 04/03/25 at 2:47 p.m., an administrative staff member (#1) confirmed staff failed to notify the physician of Resident #1's high blood sugar levels on the above dates.

355060 04/03/2025

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

Review of Resident #293 toileting chart on the afternoon of 3/31/2025 showed staff toileted the resident at 01:33 p.m. and 05:00 p.m. (39 minutes after the incontinent episode observed in the activity room).

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

The facility staff failed to toilet Resident #293 as care planned.

355060 04/03/2025

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

The facility failed to ensure Resident #243's anti-rollbacks were properly positioned while being transferred up/down the van ramp.

Based on the following information, non-compliance at 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.

355060 04/03/2025

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

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.

355060 04/03/2025

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

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.

Based on record review, review of facility policy and staff interview, the facility failed to ensure

medication for 1 of 1 sampled resident (Resident #37) who received PRN psychotropic medications.

Failure to ensure PRN psychotropic medication orders are limited to 14 days and document a rationale for continued use places residents at risk for receiving unnecessary medications and experiencing adverse consequences related to their use.

Findings include: Review of the facility policy titled Psychotropic Medications occurred on 04/03/25.

This policy, dated December 2024, stated, . PRN orders for psychotropic drugs are limited to 14 days. 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 should document their rationale in the resident's medical record and indicate the duration for the PRN order.

Review of Resident #37's medical record occurred on all days of survey.

Diagnoses included dementia and anxiety.

Physician's orders included the following: * 12/17/24 Ativan (an antianxiety medication) 0.5 milligrams (mg) every six hours PRN for restlessness, agitation, and anxiety.

The order failed to include an end date. * 01/14/25 (28 days after the initiation of the Ativan), Ativan 0.5 mg at 4:00 p.m. and continue 0.5 mg every six hours PRN for agitation, restlessness and anxiety for 90 days.

The medical record lacked a rationale for continued use of the PRN order. * 03/04/25 (20 days after the last review), the provider changed the Ativan order to 0.5 mg twice a day at 4:00 p.m. and bedtime and to continue PRN Ativan 0.5 mg every six hours as needed for agitation, restlessness and anxiety 60 days.

A provider note, dated 03/04/25, stated, overall improved and not so problematic .

The medical record lacked a rationale for continued use of the PRN order.

During an interview on 04/03/25 at 1:37 p.m., an administrative staff member (#1) stated she expected staff/physicians to follow the facility's policy regarding PRN psychotropic medication orders.

355060 04/03/2025

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

Based on observation, facility policy, record review and staff interview the facility failed to ensure

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.

355060 04/03/2025

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

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.

355060 04/03/2025

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

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.

355060 04/03/2025

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

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-F657, F-F725, F-F761, F-F804, F-F812, and F-F880 as indicated by deficiencies cited during the last standard survey on 02/29/24.

Refer to the F-F657, F-F725, F-F761, F-F804, F-F812, and F-F880 for specific findings.

During an interview on 04/03/25 at 12:00 p.m., two administrative staff members (#18 and #19) indicated they developed a plan of correction, conducted audits throughout the year, and monitored performance.

They also completed spot audits to ensure improvements were maintained.

Failure of the facility to effectively utilize QA resulted in continued noncompliance in the following areas: * F-F657 Care Plan Revisions * F-F725 Sufficient Nursing Staff * F-F761 Label and Store Medications * F-F804 Palatable Foods * F-F812 Store, Prepare, and Serve Food in Sanitary Manor * F-F880 Infection Control

355060 04/03/2025

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

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

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.

355060 04/03/2025

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

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.

355060

Form Approved OMB

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

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

*

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], 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 .

355060

Form Approved OMB

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