Deficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
28% worse than North Dakota average
North Dakota average: 3.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jun 26, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, medication administration, bowel management, infection control, and resident safety.
Findings
The facility failed to ensure accurate coding of resident assessments (MDS), proper insulin administration and monitoring, adherence to bowel management protocols, adequate supervision to prevent elopement, and proper infection control practices related to Enhanced Barrier Precautions. These deficiencies posed minimal harm or potential for actual harm to a few residents.
Deficiencies (5)
Failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 17 sampled residents, including failure to code cancer diagnosis, internal bleeding, and antibiotic use.
Failed to ensure staff followed professional standards for insulin use and preparation, including failure to notify physician of out-of-range blood sugar levels and improper priming of insulin pens.
Failed to ensure appropriate care and services for fecal impaction by not following bowel management protocol interventions for 1 sampled resident.
Failed to ensure adequate supervision and monitoring to prevent elopement for 1 sampled resident with dementia, including failure to assess and address elopement risk and implement individualized interventions.
Failed to follow infection control standards for Enhanced Barrier Precautions by not wearing gowns during high-contact resident care and transfers for 2 sampled residents.
Report Facts
Residents sampled for MDS coding: 17
Residents sampled for insulin use: 2
Residents sampled for fecal impaction: 1
Residents sampled for elopement risk: 1
Residents sampled for infection control: 2
Blood sugar readings over 400 mg/dl: 4
Dates of Resident #25 hospitalizations: 2
Date of survey completion: Jun 26, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS staff member (#7) | Confirmed staff failed to accurately code the MDS. | |
| Nurse (#5) | Observed priming insulin pen horizontally, not as per manufacturer instructions. | |
| Administrative nurse (#1) | Stated expectations for insulin pen priming and notification of out-of-range blood sugar levels; confirmed lack of bowel protocol implementation. | |
| Certified Nursing Aide (CNA) (#6) | Observed removing gown and gloves but assisted with resident transfer without gown. | |
| Certified Nursing Aides (#3 and #4) | Failed to apply gowns prior to transferring Resident #117. | |
| Administrative staff member (#2) | Expected staff to wear gowns during high-contact resident care/transfers for residents on Enhanced Barrier Precautions. | |
| Administrative staff member (#1) | Verified lack of documentation of elopement risk assessment and failure to implement individualized interventions for Resident #49. |
Inspection Report
Routine
Deficiencies: 3
Date: Jun 12, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, resident assessments, infection prevention and control, and accurate coding of resident data.
Findings
The facility failed to notify a physician about a resident's refusal of prescribed medication, inaccurately coded medication and hospice status on resident assessments, and did not consistently follow infection prevention and control standards including proper use of PPE and hand hygiene.
Deficiencies (3)
Failure to notify the physician of a resident's rejection of a prescribed medication (Ativan).
Failure to ensure accurate coding of the Minimum Data Set (MDS) for medications and hospice status for 3 residents.
Failure to follow infection prevention and control standards including proper use of PPE and hand hygiene for 6 residents.
Report Facts
Medication refusals: 7
Sampled residents: 18
Residents observed for infection control: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse (#4) | Stated the facility does not have a policy related to notification of the physician and confirmed incorrect MDS coding. | |
| Supervisory nurse (#12) | Stated she would inform the doctor if a resident repeatedly refused medication but was unaware if staff notified the doctor of Resident #2's refusal. | |
| Nurse manager (#11) | Stated staff missed coding hospice on the MDS and that opioid should have been coded. | |
| Staff nurse (#10) | Failed to don appropriate PPE when entering Resident #65's room. | |
| Administrative nurse (#3) | Expected staff to remove gloves and perform hand hygiene when moving from dirty to clean tasks and confirmed Resident #65 was on Enhanced Barrier Precautions. |
Inspection Report
Routine
Deficiencies: 3
Date: Jun 12, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, resident assessments, and infection prevention and control practices at St Gabriel's Community nursing home.
Findings
The facility failed to notify a physician of a resident's repeated refusal of prescribed medication, inaccurately coded Minimum Data Set (MDS) assessments for several residents, and did not consistently follow infection prevention and control standards, including proper use of personal protective equipment (PPE) and hand hygiene.
Deficiencies (3)
Failure to notify the physician of a resident's rejection of prescribed Ativan medication.
Failure to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 18 sampled residents, affecting assessment accuracy.
Failure to follow infection prevention and control standards including improper hand hygiene and PPE use for 6 of 15 sampled residents.
Report Facts
Medication refusals: 7
Sampled residents with inaccurate MDS coding: 3
Sampled residents with infection control deficiencies: 6
Total sampled residents for infection control: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nurse (#4) | Stated the facility does not have a policy related to notification of the physician and confirmed MDS coding errors. | |
| Supervisory nurse (#12) | Stated she would inform the doctor if a resident repeatedly refused medication but was unaware if notification occurred for Resident #2. | |
| Nurse manager (#11) | Confirmed missed coding of hospice and opioid medications on MDS. | |
| Certified Nurse Aides (#5, #6, #7, #8, #9) | Observed failing to perform proper hand hygiene and PPE use during resident care. | |
| Staff nurse (#10) | Failed to don appropriate PPE when entering Resident #65's room. | |
| Administrative nurse (#3) | Expected staff to remove gloves and perform hand hygiene when moving from dirty to clean tasks and confirmed Resident #65 was on Enhanced Barrier Precautions. |
Inspection Report
Routine
Deficiencies: 4
Date: Jul 13, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, care quality, and PASRR screening processes at St Gabriel's Community nursing facility.
Findings
The facility was found deficient in maintaining a safe and clean environment for residents on oxygen, failed to complete required PASRR status change and re-screenings for certain residents, and did not accurately transcribe medication orders leading to discrepancies between physician orders and medication administration records.
Deficiencies (4)
Failure to ensure a safe, clean, comfortable, homelike environment for 1 of 5 sampled residents on oxygen due to unclean personal fan and oxygen concentrator filter.
Failure to complete a status change assessment for 1 of 2 sampled residents reviewed for PASRR, resulting in potential delivery of care inconsistent with resident needs.
Failure to complete a Level I PASRR for 1 of 2 sampled residents within 30 days, increasing potential for not identifying needed mental health services.
Failure to transcribe a medication order accurately and verify the correct medication during administration for 1 of 5 residents, risking wrong medication administration.
Report Facts
Residents sampled: 5
Residents sampled: 2
Medication dosage: 8.6
Medication tablets: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| administrative staff member (#1) | Stated expectation for staff to clean dirty equipment in residents' rooms and confirmed medication transcription error | |
| administrative staff member (#2) | Confirmed failure to complete PASRR change in status Level I screen and Level I re-screen | |
| North Dakota PASRR consultant agency staff member (#3) | Provided expert opinion on PASRR screening requirements and status changes | |
| nurse (#4) | Observed administering medication during med pass | |
| supervisory nurse (#5) | Verified medication label discrepancy |
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