Sunset Drive - A Prospera Community

F-F604 is considered past non-compliance. The facility implemented corrective action for the resident affected by the deficient practice by:

* Completing an investigation following the incident, and

* Determining the nurse failed to follow policy in implementing a restraint.

The facility implemented measures to ensure the deficient practice does not recur as follows:

*Placed the nurse (#2) on administrative leave on 06/09/24 to protect all residents during the investigation.

The nurse (#2) terminated from her employment on 06/17/24 after completion of the investigation.

* Provided the CNAs (#3 and #4) with re-education related to Abuse and Neglect during their interviews on 06/09/24, to include reporting of incidents such as the above to the on-call nurse or Director of Nursing in a timely manner. Additionally, the CNAs were required to review the Proper Use of Restraints PowerPoint by 6/14/2024.

* Disseminated the Proper Use of Restraints PowerPoint on 06/14/24 to all units and required all staff to read and acknowledge.

* Reassigned all staff the Abuse and Neglect of the Vulnerable Adult module, with a due date of July 15, 2024. Additionally, staff are expected to continue to complete this module annually.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 3 355065 Department of Health & Human Services Printed: 09/23/2025 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 355065 B. Wing 06/19/2024

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

Sunset Drive - A Prospera Community 1011 Boundary St NW Mandan, ND 58554

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 0604 * All new hires expected to complete the Abuse and Neglect of the Vulnerable Adult module in the Success Center (online learning program), and review and acknowledge the Proper Use of Restraints PowerPoint. Level of Harm - Minimal harm or potential for actual harm * Review the Abuse and Neglect policy and expectations at an all-staff meeting planned for 06/25/24 at 7:00 a.m. and 2:30 p.m. Residents Affected - Few

This surveyor determined a deficient practice existed on 06/07/24. The facility implemented corrective action by 06/14/24 and continues with staff education and monitoring for restraint use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 3 355065