Inspection Reports for
SMP Health – Ave Maria
421 18th Street NE, Jamestown, ND, 58401
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% better than North Dakota average
North Dakota average: 3.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Routine
Deficiencies: 3
Date: Sep 11, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident rights, medication labeling, infection prevention and control, and other care practices at the nursing home.
Findings
The facility was found deficient in maintaining resident dignity by failing to properly cover a wound vacuum container, ensuring accurate medication labeling for an insulin pen, and implementing infection prevention and control practices including hand hygiene, enhanced barrier precautions, and cleaning of a glucometer. These deficiencies were associated with minimal harm or potential for actual harm.
Deficiencies (3)
Failure to cover a wound vacuum collection container to preserve resident dignity and psychosocial well-being.
Failure to ensure accurate labeling of medications for an insulin pen, risking wrong medication or dose.
Failure to follow infection control standards including hand hygiene, enhanced barrier precautions, and cleaning of glucometer.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse (#2) | Provided confirmation and statements regarding wound vacuum container coverage, medication labeling, infection control expectations, and gown use. | |
| Nurse (#1) | Observed preparing insulin pen without proper labeling and failing to disinfect glucometer. | |
| Certified Nurse Aides (#5, #6, #7) | Observed failing hand hygiene and gown use during resident care. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 13, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging abuse of a resident by staff, specifically that a rag was placed in the resident's mouth to silence her.
Complaint Details
The complaint was substantiated. Staff reported and witnessed CNA (#5) placing a rag/towel in Resident #2's mouth to keep her quiet. Multiple staff interviews and facility investigations confirmed the abuse. The CNA was suspended pending investigation results.
Findings
The facility failed to ensure residents were free from mental and physical abuse, as evidenced by staff placing a rag in Resident #2's mouth. The investigation confirmed the abuse, and corrective actions including suspension of the involved CNA and staff re-education were implemented.
Deficiencies (1)
Failure to protect Resident #2 from mental and physical abuse, including placing a rag in her mouth to silence her.
Report Facts
Residents Affected: 1
Dates of events: Jun 7, 2024
Dates of events: Jun 10, 2024
Dates of events: Jun 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) #5 | Accused of placing rag in resident's mouth; suspended pending investigation. | |
| Certified Nurse Aide (CNA) #2 | Witnessed and reported the abuse. | |
| Certified Nurse Aide (CNA) #3 | Witnessed and reported the abuse. | |
| Managerial staff members (#6, #7, #8, #9) | Provided facility reports and investigation details. |
Inspection Report
Routine
Deficiencies: 2
Date: Oct 12, 2023
Visit Reason
The inspection was conducted to assess compliance with care and documentation standards in the nursing home, including treatment according to resident care plans and proper documentation of hospice services.
Findings
The facility failed to provide appropriate treatment for one resident by not applying prescribed heel protecting boots, and failed to maintain required hospice documentation for three residents receiving hospice services.
Deficiencies (2)
Failure to provide treatment in accordance with the resident's plan of care for a diabetic heel ulcer by not applying heel protecting boots as ordered.
Failure to ensure residents' records contained the hospice election form and certification of terminal illness for residents receiving hospice services.
Report Facts
Residents affected: 1
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| nurse (#2) | Entered Resident #49's room and gave heel boots to CNAs | |
| certified nurse aides (#3 and #4) | Received heel boots to apply to Resident #49 | |
| administrative nurse (#1) | Confirmed missing hospice documentation during interview |
Inspection Report
Routine
Deficiencies: 2
Date: Oct 12, 2023
Visit Reason
The inspection was conducted to assess compliance with care and documentation standards in the nursing home, including treatment adherence and hospice service documentation.
Findings
The facility failed to provide treatment according to the resident's plan of care for one resident with a diabetic heel ulcer by not applying heel protecting boots as ordered. Additionally, the facility failed to ensure hospice election forms and certifications of terminal illness were present in the medical records for three residents receiving hospice services.
Deficiencies (2)
Failure to provide treatment in accordance with the resident's plan of care by not applying heel protecting boots as ordered for Resident #49.
Failure to ensure residents' records contained the hospice election form and certification of terminal illness for 3 of 4 sampled residents receiving hospice services.
Report Facts
Residents affected: 1
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| nurse (#2) | Entered Resident #49's room and gave heel boots to CNAs | |
| certified nurse aides (#3 and #4) | Received heel boots for Resident #49 | |
| administrative nurse (#1) | Confirmed missing hospice election form and certification |
Inspection Report
Routine
Deficiencies: 2
Date: Sep 29, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control standards, including disinfecting shared equipment and performing aerosol-generating procedures.
Findings
The facility failed to properly disinfect mechanical lifts between resident uses and did not consistently follow aerosol precaution protocols during breathing treatments, posing a potential risk of infection transmission to residents, staff, and visitors.
Deficiencies (2)
Failure to disinfect mechanical lifts after use and prior to entering another resident's room.
Failure to follow aerosol precaution protocols during breathing treatments, including not wearing eye protection and not closing the door.
Report Facts
Residents sampled: 20
Residents affected: 5
Breathing treatments per day: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant (CNA) | Multiple CNAs (#2, #3, #5, #7, #8) failed to disinfect mechanical lifts after use | |
| Staff Nurse | Staff nurse (#6) involved in mechanical lift transfer where disinfection was not performed | |
| Medication Assistant (MA) | MA (#9) failed to wear eye protection and close door during breathing treatment | |
| Administrative Nurse | Administrative nurse (#1) stated expectations for disinfecting lifts and aerosol precautions |
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