Every finding on record at Magnolia Manor Methodist NSG C

Based on observations, staff interviews, record review, and review of the facility policy titled, Care Plans-Comprehensive Person-Centered the facility failed to implement appropriate individualized interventions on the comprehensive care plan for a resident requiring oxygen therapy management for one of 24 residents (R) (R65) receiving oxygen. This deficient practice had the potential to place the residents at risk for unmet care needs.Findings include:Review of the undated policy Care Plans-Comprehensive Person-Centered revealed under procedural guidelines: . 2. The care plan is developed from the resident assessment (MDS (minimum data set) and in coordination with the attending physician's regimen of care.Review of the electronic medical record (EMR) for R65 revealed diagnoses that included butare not limited to unspecified asthma, uncomplicated.Review of Physician Orders dated 03/24/2026 for R65 revealed orders for oxygen at two liters per minute (LPM) via nasal canula (NC).Review of the care plan for R65 revealed the resident required oxygen therapy related to respiratory disease. Interventions failed to include individualized or specific care interventions that would give the resident the highest practicable physical level, including medical interventions related to the physician order regarding the administration of medications as prescribed or per standing order.Interview on 04/30/2026 at 12:30 PM with MDS Coordinator AA revealed that R65's oxygen care plan interventions should include individualized medical interventions related to the flow rate so that clinical staff were aware of the prescribed rate so they are able to monitor for hypoxia (low oxygen level) and the resident's drive to breath. She confirmed that the resident's care plan was lacking specific/individualized interventions related to oxygen such as follow physician order for flow rate. She revealed that after she was notified the resident's flow rate was on the wrong setting during the survey, it prompted her to review the care plan, and she updated it to include appropriate interventions related to oxygen including Administer oxygen at rate prescribed by medical provider.

Based on observations and staff interviews, the facility failed to ensure an environment free from potential hazards by not removing aerosol cans from the bedside for two of 50 sampled residents (R) (R34 and R37). This deficient practice increased the risk of potential accidents. Findings include: 1. Observations on 04/28/2026 at 11:42 AM, 04/29/2026 at 10:33 AM, and 04/30/2026 at 10:12 AM of R37's room revealed one aerosol container (air freshener) placed on top of the nightstand located next to R37's bed. During an interview on 04/30/2026 at 10:43 AM, Nurse Supervisor Licensed Practical Nurse (LPN) GG and Certified Nursing Assistant (CNA) HH confirmed the aerosol container was present in R37's room. Both staff stated that aerosol containers were not permitted in resident rooms due to safety concerns for residents who wander. CNA HH and LPN GG immediately removed the aerosol container from R37's room at the time of the interview. During an interview on 04/30/2026 at 11:48 AM, the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) confirmed the aerosol container was present in R37's room and stated that aerosol items were not permitted in resident rooms. 2. Observation conducted on 04/28/2026 at 11:42 AM, 04/29/2026 at 9:29 AM, and 04/30/2026 at 10:37 AM in R34's room revealed five aerosol containers (deodorant spray and dry shampoo hairspray) placed on top of one of two nightstands located at R34's bedside. During an interview on 04/30/2026 at 10:43 AM, LPN GG and CNA FF confirmed that aerosol containers were present in R34's room. Both staff confirmed aerosol containers were not permitted in resident rooms, particularly due to safety concerns for residents who wander. CNA FF and LPN GG immediately removed the aerosol containers from R34's room at the time of the interview. During an interview on 04/30/2026 at 11:41 AM, the Infection Preventionist (IP) confirmed that aerosol containers were present in R34's rooms and revealed aerosol containers were not permitted in resident rooms. During an interview on 04/30/2026 at 11:48 AM, the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) confirmed aerosol containers were present in R34's room and stated aerosol containers were not permitted in resident care areas.

Based on observations, record review, staff interviews, and review of the facility's policy titled, Oxygen Therapy, the facility failed to ensure the physician's order for oxygen administration was followed for one of 24 Residents (R) (R65) reviewed for oxygen administration. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs and a diminished quality of life.Findings include:Review of the facility's undated policy titled Oxygen Administration under the section titled Intent revealed: It is the intent of (corporate name) facilities to ensure that oxygen is administered appropriately to residents to improve oxygenation and provide comfort to residents experiencing respiratory difficulties.Review of the electronic medical record (EMR) for R65 revealed diagnoses that included but are not limited to unspecified asthma, uncomplicated.Review of 65's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed, Sections C (Cognitive Patterns), a Brief Interview of Mental Status (BIMS) score of 00, indicating R65 was unable to complete, Section O (Special Treatments and Programs), respiratory therapy.Review of Physician Orders for R65 dated 03/24/2026 revealed orders for oxygen at two liters per minute via nasal canula.Observations on 04/28/2026 at 11:18 AM and 3:08 PM, and 04/29/2026 at 9:04 AM revealed R65's oxygen rate set at 3 LPM. Observation and rounding on 04/29/2026 at 10:08 AM with the Director of Nursing (DON) confirmed R65's oxygen order was for 2 LPM. The DON verified the resident's oxygen rate was set at 3 LPM instead of 2 LPM. When shown pictures from observations from 4/28/2026 at 11:18 AM and 3:08 PM with oxygen rate set on 3 LPM, the DON revealed nurses should check the oxygen rate to match the physician order at least once a shift, usually during medication pass.Interview on 04/29/2026 at 10:10 AM with Registered Nurse (RN) BB revealed she was the nurse assigned to R65 on 04/29/2026. She stated she completed the resident's medication pass earlier and admitted she did not verify the residents concentrator to confirm the oxygen rate was on the prescribed setting and confirmed the order was for 2 LPM.

Based on record reviews, interviews and the facility policy titled Surveillance for Infections, the facility failed to follow the Department of Public Health (DPH) recommendations for diagnostic testing for 33 symptomatic residents on six of six Units (Unit 1, Unit 2, Unit 3, Unit 4, Unit 5, Unit 6) involved in an epidemiological qualified infectious disease outbreak. The deficient practice increased the risk for continued spread of infection.Findings includeReview of the policy Surveillance for Infections revised September 2017 documented under Policy Interpretation and Implementation: 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infections, to guide appropriated interventions and to prevent future infections. 8. a. The Infection Preventionist and the Attending Physician will determine if laboratory tests are indicated, and whether special precautions are warranted.Review of the gastrointestinal illness (GI) outbreak synopsis provided by the facility, documented the Department of Public Health (DPH) was contacted on 12/12/2025 regarding guidance for a potential outbreak of Norovirus. Review of the Infection Outbreak Mapping document for the GI symptoms indicated six of six units were affected.Review of the Line listing of resident and staff with symptoms dated 12/9/2025 through 12/17/2025 documented the residents and staff that developed symptoms of nausea and/or vomiting and diarrhea during that time frame. There was a total of 33 residents and 13 staff members listed with the final date of symptom onset of 12/17/2026 affecting a resident. Review of the communication with DPH dated 12/12/2025 documented that DPH was contacted for guidance and reporting for an outbreak of possible Norovirus without a diagnostic confirmation. DPH responded on 12/15/2025 with a recommendation for individuals who are experiencing diarrhea to receive testing and asked if the facility was contracted with a commercial lab.Review of the physician standing order dated 1/28/2026 documented that if the facility has any notification with treatment or testing recommendations sent by the health department or other entities, to document that you have received them and that you have sent (preferably fax) to the Physician and retain a copy at the facility for his next visit. This will prevent communication errors. In addition, it was documented that staff may also call and let him know the fax has been sent.During an interview on 1/28/2026 at 10:28 AM with LPN AA Quality Assurance Director/Infection Preventionist, it was revealed that there were 33 residents and 13 staff with symptoms that included a combination of nausea and/or vomiting, diarrhea, and some with temperatures.During an interview on 1/29/20261/28/2026 at 11:28 AM with the Medical Director/Physician (MD) revealed that he routinely does not order stool samples for culture. The patients had diarrhea for 2-3 days and the treatment they were getting was fluids, Imodium and Zofran. MD stated that he was unaware of the DPH recommendation to collect stool samples and if he was informed that he would follow the DPH recommendation. During an interview on 1/28/2026 at 12:07 PM, the Nurse Practitioner (NP) revealed she saw some of the residents at the facility with vomiting/diarrhea during the outbreak in December 2025. NP stated she was aware of the recommendation to test for Norovirus but declined the recommendation for the residents under her care. NP stated the treatment plan would be the same and the residents were already receiving treatment from the primary care provider. NP stated by the time the recommendation was received from DPH and communicated there were no longer any residents with signs and symptoms.During an interview on 1/29/2026 at 3:16 PM with the Director of Nursing (DON), it was revealed she was not aware that the Infection Preventionist nurse had listed a diagnosis for DPH and should have listed only the symptoms. The DON confirmed the physician should have been informed of the DPH recommendation.During an interview on 1/29/2026 at 4:14 PM with the Administrator, it was revealed that she did not know the type of virus in the facility. The Administrator confirmed the report to DPH should have described the symptoms with the treatment prescribed according to the doctor's order.

Based on observation, record review, staff interviews and the facility policy titled Restraints/Bed Rails, the facility failed to ensure one resident (R) (R1) from a sample of 11 residents was free from being restrained with a gait belt while in a wheelchair. The deficient practice placed R1 at risk of adverse clinical outcomes. Findings includeReview of the policy Restraints/Bed Rails dated October 2016, documented, under Intent: It is the intent of the (named) facility that right of residents to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms is honored at all times.Review of the medical records revealed R6 was admitted to the facility on [DATE], with the following diagnoses that included but are not limited to type 2 diabetes mellitus, mood disorder, hypertension, chronic obstructive pulmonary disease, and benign prostatic hyperplasia.Review of the quarterly Minimum Data Set (MDS) for R6 with an Assessment Reference Date (ARD) of 11/19/2025 revealed a Brief Interview for Mental Status (BIMS) score of 1 which indicated severe cognitive impairment. Review of the care plan dated 6/11/2025 revealed R6 showed signs and symptoms of cognitive decline with most recent Basic Interview for Mental Status test score of 5 compared to 9 on 3/10/2025. Care Plan Approaches documented, set expectations and limits for resident; respect resident rights to make decisions.Review of the progress notes dated 11/10/2025 through 1/11/2026 revealed a situation involving staff using a gait belt to restrain R6 to his wheelchair. The responsible party was notified about the incident, and the resident did not sustain any injuries.Observation on 1/27/2026 at 1:06 PM revealed R6 was sitting in a high back wheelchair with leg rest and foot pedals. R6 was at a table being assisted with lunch.During an interview on 1/29/2026 at 12:47 PM with Licensed Practical Nurse (LPN) HH revealed that she received a call from Certified Nursing Aide (CNA) II who informed her of R6 being tied to a wheelchair with a gait belt. LPN HH stated she immediately called LPN MM Unit Manager who notified the Director of Nursing (DON.)Interview on 1/29/2026 at 2:28 PM with CNA II revealed that R6 was up because he kept getting out of bed, even with mats at the bedside and was placed in his wheelchair. CNA II stated R6 started yelling about wanting to go to bed and he was a Hoyer lift transfer. CNA II stated when she was hooking the pad to the lift, she saw the gait belt was wrapped around the top portion of the resident and the outer part of the back of the wheelchair. CNA II confirmed she immediately notified LPN HH, removed the gait belt and placed R6 in his bed. Interview on 1/29/2026 at 3:16 PM with the Director of Nursing (DON) revealed that CNA DD was terminated for substantiated abuse. Interview on 1/29/2026 at 4:14 PM with the Administrator revealed that it is her expectation that no residents be restrained.

Based on observations, interviews, and a review of records, facility staff failed to ensure the appropriate medical evaluation of a resident that sustained a head injury during a fall. This resident was at an increased risk for the development of intracranial hematomas (accumulations of blood inside the skull, either within the brain or between the brain and the skull) due to head injury, advanced age, and the use of antiplatelet agents. This deficient practice affected one of two residents reviewed for falls from a total of 37 residents sampled [Resident (R)#119]. Actual harm was identified on 3/5/25 when R#119 experienced a fall with injury which led to a decline in abilities and the facility failed to provide timely follow up for the decline. Findings include: According to Merck Manual (accessed 3/13/25 https://www.merckmanuals.com/home/injuries-and-poisoning/head-injuries/intracranial-hematomas), For people who are taking aspirin or anticoagulants (which increase the risk of bleeding), particularly older adults, the risk of developing a hematoma after even a minor head injury is increased . Some hematomas, particularly subdural hematomas, may develop slowly and cause gradual confusion and memory loss, especially in older adults. These symptoms are similar to those of dementia. People may not remember the head injury. Diagnosis of intracranial hematomas is usually based on results of computed tomography (CT). A review of R#119's medical record revealed an initial admitted [DATE]. R#119's medical history included dementia and repeated falls. An admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/5/25 revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 possible points, indicating no cognitive impairment. According to the assessment, R#119 had no disorganized thinking or altered level of consciousness. According to an admission note dated 1/30/25 at 4:17 a.m., R#119 was alert and oriented to person, place, and time. The note further described Resident #119 as having clear, coherent speech with the ability to make his needs known. On 3/11/25 at 12:56 p.m., R#119 was observed lying in his bed on his left side with his eyes closed. A large, raised, bruised area was noted to be encompassing the resident's right eye and surrounding area. The bruising and discoloration extended down the resident's right cheek. R #119's bed was pushed against the wall and three fall mats were observed on the floor. On 3/12/25 at 1:10 p.m., a follow up interview was attempted with R #119. He was sitting in his wheelchair and was positioned at a dining table. When asked about the injury to his right eye, Resident #119 initially presented with garbled speech and struggled to formulate a response but eventually stated, I fell . R#119 added that he was tired. When asked about the circumstances of the fall that led to the injury, R#119 again stated he was tired and declined to explain the circumstances of the fall. A preliminary review of R#119's medication orders revealed an order, dated 1/29/25, for Plavix 75 milligrams (mg) to be administered once daily. A second order, dated 1/29/25, was noted for Aspirin 325 mg to be administered once daily. Subsequent review of R#119's nursing progress notes revealed a note dated 3/4/25 at 7:43 p.m. The note indicated that the resident was observed lying on his right side on the floor of his room. The note added, noted a large hematoma to the right side of fore head. [sic] The note also indicated that the Nurse Practitioner was notified of the fall and the injury and a recommendation was given to use ice if we need to. A medical provider note by the Nurse Practitioner, dated 3/5/25 at 11:52 a.m., identified R#119 as having a fall from bed on 3/4/25 which resulted in a hematoma to the right side of his forehead. A narrative in the note indicated that R#119's responsible party was notified of the fall and the hematoma. According to the note, the responsible party was advised that R#119 needed a CT scan of his head performed to rule out bleeding related to R#119 receiving Plavix and Aspirin. The responsible party declined to have R#119 transferred to the hospital. The Nurse Practitioner explained to the responsible party that R#119 was at risk for major injuries, but R#119 was ultimately not transferred to the hospital for a CT scan. The note did indicate that R#119's Plavix and Aspirin were placed on hold for 7 days. A review of R#119's medication administration record for March 2025 revealed that facility staff continued to administer the Aspirin and the Plavix for two additional days (3/5/25 and 3/6/25) after the development of the hematoma. The order to hold both medications was eventually entered by the Nurse Practitioner late in the day on 3/6/25. A note by the Social Services department on 3/5/25 at 3:12 p.m. described a wellness visit being conducted with R#119. Resident #119 was described as presenting with confusion, unable to articulate full sentences, and was rambling with slurred/unclear speech. The note also identified R#119 as having excessive saliva spewing from both sides of his mouth during the encounter. The Social Services employee attempted to conduct a BIMS which resulted in a score of 2 out of 15 possible points, indicating severely impaired cognition. According to the note, R#119 had previously scored 15 out of 15 possible points, indicating there was no cognitive impairment at that time. The Social Worker notified the MDS Nurse of her findings. A note by the MDS Nurse, dated 3/5/25 at 3:39 p.m., read, Resident was observed to be drooling, drooling would increase when resident would start concentrating on attempting to stand. When staff would wipe his mouth, he would curse at them, speaking clearly, then start speaking unclearly again. When asked how he was doing, he glared at writer, then looked away without answering. A nursing progress note, dated 3/6/25 at 4:28 a.m., described R#119 as being observed on the floor. The note included a narrative which read, Resident continued to curse, yelling out, and speak clearly and then rambling unclearly after. A nursing progress note dated 3/7/25 described R#119 as being alert but not oriented. The note described R#119 as being very combative today and described behaviors such as yelling, cursing, and attempting to strike staff. A medical provider was notified, and new orders were obtained for Ativan (an anxiolytic medication) to be administered via intramuscular injection. A nursing progress note, dated 3/9/25 at 10:30 p.m., described R#119 as being observed on the floor mat beside his bed. R#119 continued with combative behaviors and agitation. A medical provider was notified, and new orders were obtained for Haldol (an antipsychotic medication) to be administered via intramuscular injection immediately. Continued review of R#119's progress notes through 3/13/25 revealed a continuing and progressive decline in his medical condition from the time of admission and since sustaining a fall with head injury. Review of neurological flow sheets from 3/4/25 through 3/6/25 revealed that, on 3/4/25, R#119's speech was documented as clear. On 3/5/25 beginning at 10:00 a.m. through 3/8/25 at 7:00 a.m., R#119's speech was documented as rambling. On 3/13/25 at 11:18 a.m., an interview was conducted with the Administrator, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON), to discuss the concern regarding R#119's progressive decline since admission and since sustaining a fall with head injury. The DON stated, We will get some results. When asked why R#119 had not undergone a CT scan as recommended by the Nurse Practitioner, the Administrator and DON explained that R#119's family member declined to have the resident transferred, but that facility staff continued to monitor the resident in house through neurological assessments. When asked what the facility's typical response would be when a resident sustained a fall with a head injury while receiving anticoagulant and/or antiplatelet agents, the DON stated the resident would likely be transferred to the hospital for evaluation. On 3/13/25 at 11:27 a.m., R#119 was observed sitting in his wheelchair in the Unit 4 Day Room attending an activity by the facility's Chaplain. When the Chaplain began singing and playing a guitar, R#119 attempted to leave the activity but was redirected by a staff member. R#119 pointed to his head and complained of a headache. A subsequent observation, on 3/13/25 at 11:37 a.m., revealed R#119 was drowsy and leaning forward in his wheelchair. R#119 was awakened by a staff member and encouraged to sit up straight in his wheelchair. On 3/13/25 at 11:50 a.m., an interview was conducted with the Unit 4 Nurse Manager (NM). The NM confirmed she was familiar with R#119's care and needs. The NM identified R#119 as being increasingly more confused since admission to the unit with intermittently unclear, garbled speech. The NM confirmed that R#119's overall condition was a little worse than it was at admission. When asked whether R#119 had undergone a CT scan since the fall with head injury on 3/4/25, the NM explained that the resident's responsible party declined to have the resident transferred to the hospital for the scan. When asked what the facility's typical response would be in the event that a responsible party was not acting in the best interest of the resident, the NM explained that nursing staff would have the capability to transfer the resident to the hospital. When asked why R#119 had not been transferred despite the strong recommendation from the Nurse Practitioner and the resident's progressive decline, the NM stated the facility decided to monitor R#119 in house. On 3/13/25 at 12:00 p.m., an interview was conducted with the Social Worker. The Social Worker confirmed she was familiar with R#119's medical condition from admission to current. When asked to describe R#119's condition on admission, the Social Worker described R#119 as being able to formulate complete sentences and thoughts. The Social Worker added that, at times, R#119 would have unclear speech patterns, but that they were much more infrequent than at the current time. The Social Worker added that she identified a clear, significant change in R#119's condition after her wellness visit with the resident on 3/5/25. On 3/13/25 at 2:06 p.m., a follow up interview was conducted with the DON and ADON. The DON stated, We stand by our decision not to send him to the hospital. We are confident in our staff. We have reviewed neurochecks and notes from his provider and we definitely stand by our decision. The DON was then asked to review the copies of neurocheck forms, which were produced earlier in the day. Both the DON and ADON reviewed the forms and stated they could not explain the documented discrepancies and changes with R#119's speech patterns. On 3/13/25 at 3:36 p.m., a telephone interview was conducted with R#119's family member. The family member confirmed that R#119's cognition was intact and that his speech was clear and coherent at the time he was admitted to the facility. When asked whether she was notified of R#119's fall on 3/4/25 which resulted in a head injury, the family member confirmed she had been notified and that she did decline R#119's transfer to the hospital for evaluation. When asked whether she was aware of R#119's medical decline, the family member explained that a nurse had called her earlier in the morning on 3/13/25 and that she told the caller to send R#119 for a CT scan. On 3/14/25 at approximately 9:30 a.m., the DON confirmed that R#119 had been scheduled for a CT scan and would be transported to the appointment by facility staff. 44785

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure food safety, sanitary conditions and the prevention of foodborne illness were maintained. This was evidenced by one of one walk-in freezer temperature gauges that displayed multiple temperatures greater than 20 degrees Fahrenheit (F) by three internal thermometers, which lead to food thawing. Additional failures included a large quantity of raw chicken pieces allowed to sit, unrefrigerated, in the frying area of the kitchen for more than four hours before placing the remaining unused portions into the same freezer with elevated temperature for storage. The facility staff failed to ensure meals served from the steam table were served under sanitary conditions by failing to change gloves, perform hand hygiene when staff changed job duties, ensuring hairnet and beard guards were used, and failed ensure steam table pan covers and food were protected from chemical contamination. This deficient practice impacted 131 of 139 residents that received an oral diet. The findings include: A review of the facility policy titled, Food Storage, not dated, revealed, Procedures .17. Freezer Temperatures: a. Temperatures for freezers should be 0 [zero] degrees or below and must be recorded daily. b. Frozen foods must be received frozen. Do not accept frozen foods which have begun to thaw. c. Holding temperatures for frozen foods is 0 [zero] degrees or below. Frozen meat must be defrosted in a refrigerator on a tray on a lower shelf. Defrosting time will depend on the size of the product. d. Every freezer must be equipped with an internal thermometer, even if equipped with an external thermometer. e. Rewrap packages of frozen food which have been opened. This prevents freezer burns and spoilage. f. Do not refreeze food which has been thawed. g. To freeze leftover food, package in small airtight units for quick freezing, label and date. h. Do do not crowd food. Proper air circulation ensures a more uniform temperature and prevents spoilage. A review of the facility policy titled, Sanitation/Infection Control, not dated, revealed, 1. Effective sanitary practices include, but are not limited to, the following: a. The Dietary Manager is responsible for supervising all sanitation and housekeeping procedures within the Dietary Department. b. The Dietary Manager and consultant dietitian develop a cleaning schedule and the Dietary Service. c. The Dietary Manager is responsible for supervising and training all personnel in proper sanitation procedures for storing, preparing and serving foods. [sic] A review of the facility policy titled, Handwashing/Hand Hygiene, with a revised date of August 2019, revealed, Policy Statement - This facility considers hand hygiene the primary means to prevent the spread of infection. Policy Interpretation and Implementation: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors . 8. Hand Hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. A review of the facility policy titled, Personal Hygiene, not dated, revealed the key to a safe and sanitary Dietary Department is healthy employees, properly trained in safe food handling, who practice good personal hygiene. Many cases of food poisoning are traced to human contamination of food. Constant training and supervision of Dietary Department personnel should stress good work habits, good health, and a clean, neat personal appearance. Head covering worn: If hair is long and not covered properly with a cap, a hair net must be worn. Hair spray is not an authorized substitute for hair nets. The head covering must be clean. A review of the facility policy titled, Dishwashing, not dated, revealed Procedure for washing pots and pans, revealed pots and pans are washed any time during or after meal preparation. The sinks are filled as needed. 1. Fill first sink with hot detergent water. 2. Fill the second sink with hot rinse water. 3. The third sink sanitizes the items by: a. Use of a chemical sanitizer added to water; or fill the sink with water kept at 180 degrees F and submerging the items for at least one minute. A review of the facility training records titled, 2024 Annual Skills Fair, dated 10/29/24 to 10/31/24 revealed the topics covered included Infection Control, Hand Hygiene: Understanding When to Wash with Soap & Water Vs Using Hand Sanitizer. All dietary staff signed the record of attendance during this training. A review of the facility's Safety Data Sheet, dated 2/13/15 revealed Magic Germicide that was observed used at the three-compartment sink was used for sanitation of the pots and pans. SECTION 2: HAZARD(S) IDENTIFCATION revealed the Globally Harmonized System (GHS), had a GHS Signal Word: DANGER, which indicated a chemical with more severe or significant hazards. GHS Hazard Phrases: H290 - May be corrosive to metals. H302 - Harmful if swallowed. IF SWALLOWED: Immediately call a POISON CENTER or physician. Rinse mouth. Do not induce vomiting. H314 - Causes severe skin burns and eye damage. H318 - Causes serious eye damage. On 3/11/25 at 10:56 a.m., an observation was made of the walk-in freezer that was equipped with three internal thermometers all reading 20 degrees F. There was food to include ice cream cups that were soft liquid, shortcake desserts thawed and had discolored patches and a shriveled appearance, hamburger patties were opened to the air and had a dull, gray-brown appearance, and a leathery appearing texture, French toast that was open and exposed to the air and had turned a brown color. These items were located throughout the freezer. Observation and interview on 3/11/25 at approximately 10:58 a.m. revealed the facility's walk-in freezer temperature log revealed no temperatures were documented from 3/1/25 to 3/3/25. The freezer temperature logs from 3/4/25 to 3/10/25 revealed temperatures ranged from 20 degrees Fahrenheit (F) to 30 degrees F. The Dietary Manager (DM) asked the dietary staff on the current shift if they were knowledgeable of the temperatures being out of range and were documented as such. The reply of three dietary staff stated they did not know who had recorded those temperatures. The DM was asked to read the temperature of three thermometers located in the rear of the freezer and was not able to accurately read the temperatures. The DM further stated the freezer's 20 degree F temperature may be up from the staff holding the freezer door open for an extended amount of time and that it would go back down. The DM stated that she expected the temperature inside the freezer to hold at zero degrees F to -10 degrees F. At 11:20 a.m., when rechecking the temperature of the walk-in freezer, the DM agreed the temperature remained at 20 degrees F but took no action. On 3/11/25 at 11:20 a.m. during a tray line observation, [NAME] LL was observed moving eight metal cooking pans with foil covers from the warmer to the steam table. She removed the foil and collected pan covers from the clean storage area under the steam table. One at a time she left the serving line, rapidly dipped the covers into the three-compartment sink beginning with the wash compartment (which contained soapy water) that was murky soiled water, dipped the pan covers into rinse water then dipped the covers into the sanitation solution then immediately removed each and placed the covers directly over the prepared pans of food. [NAME] LL failed to allow any drying time of the sanitation solution before she covered each pan. On 3/11/25 at approximately 11:24 a.m., a second observation was made with the Dietary Manager of the walk-in freezer temperature which read at 26 degrees F on each of the three thermometers located in the interior of the freezer. On 3/11/25 at 11:35 a.m., [NAME] LL was observed removing the pan covers from the steam table pans. There was a substantial amount of sanitation solution that had collected under the handles of each of the eight pan covers. [NAME] LL was observed to remove the covers, placed each in a vertical position and allowed the sanitation solution, which had collected on the top side of the pan covers, to drain into each container of food. It was at this point the surveyor stopped the serving line and asked [NAME] LL if she needed to do anything different which he/she replied no and continued to prepare for serving. She was again stopped from serving by the surveyor and again asked if she needed to change anything and she stated no and began to plate the first tray. The surveyor stopped the meal service and recommended the staff stop the tray line due to the cross contamination of the improper pan cover washing and the sanitation chemical that drained into the food. [NAME] LL left the tray line to seek advice from the DM, who was in his office. When [NAME] LL returned, she informed the dietary staff the DM had stated continue serving and don't worry about it. The serving line began without any correction. The total serving time was one hour and 10 minutes. On 3/11/25 at 1:47 p.m., an interview with the Director of Quality Assurance and Infection Control (QA/IC) stated the findings of the failure of the walk-in freezer to maintain proper holding temperature was a significant risk for foodborne illness and for residents to become sick. She also stated she expected all staff throughout the facility to use proper hand hygiene to prevent the spread of infections and germs and they should follow facility policy on hand hygiene. The Director of QA/IC stated there was a heightened risk of the spread of infection and cross contamination if staff failed to perform hand hygiene. She stated the sanitation solution should never contact food. This chemical exposure could be poisonous to the residents and the exposure could cause serious adverse reactions for certain types of medications and potentially be fatal. The Director of QA/IC stated all the findings mentioned to be extremely concerning. On 3/11/25 at 2:24 p.m., an interview with the Administrator was conducted to discuss the findings in the Dietary Department. She stated that she was not aware of any of the concerns related to the failure of the dietary staff to perform hand hygiene, to prevent cross contamination, the failure to properly maintain a properly operating freezer or the exposure of the sanitation chemicals in the food. The Administrator stated she should be made aware of any issues throughout the facility. She stated the facility had performed mock surveys prior to this date and she did not see any evidence of these issues. She stated the DM had only discussed the documentation of the freezer temperatures. The Administrator stated she took these findings very seriously and would address the concerns immediately. On 3/13/25 at 11:50 a.m., an observation was made of [NAME] MM who entered the tray line with a pair of gloves on, a hair net in place but failed to don a beard cover. An observation of [NAME] MM left the tray line seven times and returned without a glove change or performing hand hygiene. He was observed to handle four unwrapped slices of bread with the same pair of gloves in place. The bread was served onto four separate residents' meal trays. On 3/13/25 at 2:10 p.m., an observation was made of the walk-in freezer thermometer which read 20 degrees F. Upon inspection of the contents, there were 12 boxes of dairy products to include ice cream and ice cream sandwiches that were soft and had thawed to a liquid substance. There was a large black trash bag that sat inside a cardboard box stacked on two cardboard boxes. The bag was draining a white cloudy and red slimy liquid onto the floor of the freezer. The bag was open to the environment of the freezer. Inside of the bag were approximately 150 pieces of thawed chicken that had a measured internal temperature of 55 degrees F. In the bottom of the bag was the same white cloudy and red liquid that in appearance was slimy. In addition, there were boxes of thawed sausage patties, thawed hamburger patties, a box of 216 count of southern style biscuits that was thawed and had a brownish appearance and was exposed to the freezer elements, a bag that contained waffles was opened and undated. There were three freezer air circulating fans located on the front of the freezer cooling unit that were not turning. There was a buildup of ice collected under the freezing cooling unit that was dripping liquid to the floor. The DM was observed to open the box of chicken and told the utility worker to take the bag out of the freezer and to clean up the floor. The bag of chicken was observed to be placed on a utility cart while the staff cleaned the freezer floor with soap and water. On 3/13/25 at approximately 2:15 p.m., an interview with the DM was conducted and she stated the chicken was left over from the noon meal and was to be served as fried chicken. When asked how long the chicken had been left out, she stated approximately four hours, but was not clear on the exact time. She stated she expected the chicken to be placed back into the freezer if there were pieces that had not been cooked so the chicken would not spoil. When asked if she was concerned over the chicken being allowed to sit in the heated area of the deep fryer area of the kitchen for an undetermined amount of time, she stated if it was placed in the freezer, the chicken should be alright to serve for a future meal. She stated she had no concerns over the chicken being placed back in the freezer after it had been out of range for four or more hours. The DM stated she did not believe the three thermometers in the freezer were working properly and she did not think the temperature was out of range. The DM stated that she had not reported the temperature readings to maintenance for repairs. On 3/13/25 at 3:30 p.m., another observation was made of the freezer with an internal temperature of 20 degrees F. The large black bag of chicken pieces had been returned to the freezer and continued to drain a cloudy white and red liquid onto the floor of the freezer. On 3/13/25 at 4:04 p.m., a third observation was made of the large black bag inside a cardboard box that contained the thawed pieces of chicken and was noted to continue to drain the white cloudy and red liquid onto the floor of the freezer. The internal freezer temperature gauge continued to read 20 degrees F. On 3/13/25 at 4:05 p.m., the DM and Assistant Dietary Manager (ADM) were instructed by the surveyor to stop food service that utilized any contents from that freezer. The evening meal had been prepared with food items such as hamburger patties and were going to be served at the evening meal. On 3/14/25 at 9:15 a.m., an interview with the Administrator revealed she was not made aware of the concerns related to the findings of the freezer in the Dietary Department. She stated this would take priority to ensure these issues were resolved and the education of the staff would start immediately. She stated there had been some kitchen staffing changes made to address the concerns. She stated her serious concern remained of the improper workings of the freezer unit due to the risk of leading to a foodborne illness outbreak. She concluded that the single most important method of preventing illness was hand hygiene and this will be her top priority along with the improperly functioning freezer. On 3/14/25 at 10:58 a.m., an interview with the Maintenance Director II revealed he had been notified on 3/13/25 that the freezer was not working properly, and the temperature readings of the thermometers were reading out of range. He stated they had notified the Heating, Ventilation and Air Conditioning (HVAC) contractor on 3/13/25. The service technician had made a service call in the evening of 3/13/25 and determined the freezer was out of range and not in compliance with the required temperature to sustain frozen foods properly. A review of an invoice issued by the facility's air conditioning and heating vendor, dated 3/14/25 revealed the walk-in freezer was noted to have a dirty condenser coil, freezing unit was low in charge so they added refrigerant to the system, and the freezing setting was set too warm. The description noted a dirty condenser coil limits airflow and led to cleaning with special chemicals to restore proper function. On 3/14/25 at 11:10 a.m., an interview with the HVAC technician revealed their findings on 3/13/25 during a service call were that the kitchen freezer was not working properly. He stated the condenser coil was closed off with debris and was improperly circulating the coolant which kept the temperature within a set range. He stated additionally the coolant charge was low which would affect the function of the freezer's cooling system.

Based on observation, interview and record review, the facility failed to refer residents with a newly identified mental disorder or condition to the appropriate state agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation. This affected one (1) of 2 residents reviewed for PASARR Level II, Resident (R) #22. Review of the facility's policy titled Assessment of Resident Minimum Data Set/Resident Assessment Instrument (MDS/RAI), reviewed and updated October 2016, revealed: Intent - It is the intent of Magnolia Manor facilities that the MDS/RAI be completed per MDS/RAI and regulatory guidelines . Procedural Guidelines . 4. Assessments should be coordinated with the PASARR program. This includes incorporating the recommendations from the PASARR Level II determination and the PASARR evaluation into the assessment, care plan and transitions of care. Any significant change in resident's physical or mental condition should be reported to the state mental health authority or state intellectual disability authority so that a resident review can be conducted . 1.Review of the clinical record for R#22, revealed he was admitted to the facility on [DATE] with diagnoses including cerebral infarction, heart disease, hypertension, mood disorder, anxiety disorder, major depressive disorder, bipolar disorder, chronic obstructive pulmonary disease, acute kidney failure and muscle weakness. Further review of the clinical record revealed a Continuity of Care Document (CCD), which detailed the effective dates of conditions diagnosed after R #22's initial admission on 9/22/16. Among these were unspecified mood [affective] disorder, with an effective date of 4/6/18; major depressive disorder, with an effective date of 12/14/16; anxiety disorder, with an effective date of 8/20/2020; and bipolar disorder, with an effective date of 8/4/21. Three (3) of the conditions, which qualified as a possible serious mental disorder, intellectual disability, or a related condition as listed on the PASARR Level I, required a Level II review. In an interview and record review, on 3/13/25 at 4:30 p.m., the Administrator acknowledged R#22's post admission diagnoses of depressive disorder, bipolar disorder and anxiety disorder, and reported that she intended to research if any additional referrals were made. In an interview, on 3/14/25 at 8:30 a.m., the Administrator provided documentation of R#22's original PASARR Level I screen but did not locate any referrals for a Level II screening related to the subsequent diagnoses. 42070 44785

Based on observations, interviews, record review, and facility policy, staff failed to complete the assessments intended to identify deficits in ability to smoke safely for Resident (R) #22. This affected one (1) of three (3) residents sampled for smoking. The findings include: Review of facility policy entitled, Resident Smoking Guidelines, revealed: Intent - Magnolia Manor realizes the threat that smoking presents to the health and safety of the residents in our facilities . All residents who wish to smoke will be allowed to do so only in designated areas of the facility . Procedural Guidelines . 2.Resident Smoking Assessment List: A. The SSD and/or Care Plan Team Representative will assess each smoker initially, annually, with significant change and quarterly with OBRA MDS schedule to determine the amount of assistance needed and appropriately complete and/or revise the Resident Smoking Assessment List. SSD should document in the social services progress note that the assessment was completed and refer to the care plan for interventions. B. Employees responsible for the supervision of residents who smoke are responsible to inform the Care Plan Team of any changes in the level of assistance needed . Review of the clinical record revealed R #22 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, heart disease, hypertension, mood disorder, anxiety disorder, major depressive disorder, bipolar disorder, chronic obstructive pulmonary disease, acute kidney failure and muscle weakness. A list of residents who smoke was provided by the facility and included R#22 as one (1) of three (3) residents that smoke. A review of the clinical record for R#22, revealed an Annual Minimum Data Set (MDS) assessment, dated 1/31/25, which revealed R#22 with a Brief Interview for Mental Status (BIMS) score of 15, an indication of being cognitively intact. No smoking assessment from the associated evaluation period was found in the clinical record. In an interview, on 3/13/25 2:48 p.m., Social Services Assistant (SSA) AA and SSA BB reported they had not completed smoking assessments for R#22, according to the facility Smoking Policy, Social Services was responsible for the task. In an interview, on 3/13/25 at 3:18 p.m., the MDS Coordinator and MDS VV reported they did not do the smoking assessment and if one was not completed by the responsible facility staff, they would not have one. The MDS Coordinator stated she was aware R#22 smoked and added the care area to the care plan without an assessment. Both acknowledged it was not possible to know if R#22 continued to be safe to smoke without updated assessments. On 03/13/25 at 4:30 p.m., the Administrator reported only being able to locate annual smoking assessments dated 1/12/23 and 1/12/24. No quarterly smoking assessments were completed and no assessment for safe smoking was completed for the annual assessment dated [DATE]. The Administrator provided documentation of in-service training provided to the Social Services department in November 2024 which identified completion of Smoking Assessments as its responsibility. 44785

Based on observations, staff interviews, and review of facility policy titled, Medication Storage in the Care Center, the facility failed to safely store and secure medications in one of four medication rooms by leaving the medication room door unsecure and open ajar approximately three inches located in the Memory Care Unit. The deficient practice had the potential to allow unauthorized access by residents and visitors to medical equipment and medications stored in medication storage room. Findings include: Review of facility policy titled, Medication Storage in the Care Center last reviewed and updated April 2016 revealed under Procedural Guidelines: 2. Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts and medication supplies are locked or attended by persons with authorized access. Observation on 12/6/2023 at 2:46 pm on Unit 4, the Memory Care Unit, revealed the medication room on that unit is located adjacent to the nurse's station and in close proximity to the resident day room. Several residents were noted to be sitting in the day room, and no less than four residents were wandering in the hallways and entering or attempting to enter closed room doors near the medication room. The medication room door lock was found to be activated but was observed to be gapped open approximately three inches from the door frame with no staff in the vicinity of the door or in the medication room. The surveyor was able enter the medication room freely without staff interference. Unsecured cabinets with stock floor supply of over-the-counter medications were easily accessible. An observation on 12/6/2023 at 2:49 pm by Registered Nurse (RN) EE revealed, RN EE visualized the surveyor exiting the unsecured medication room and confirmed the medication room door should remain locked and secured when authorized staff are not in the room. Interview on 12/7/2023 at 10:10 am with the Director of Nursing (DON) revealed all medications, including floor stock medications, are to be secured on the medication carts and in the medication rooms. The medication carts and medication rooms must remain locked and secured at all times.

Based on observations, interviews, and review of the facility policy titled, Resident Rights, the facility failed to maintain the dignity and privacy of three of nine residents (R), R26, R45, and R280, by leaving their urinary catheter bags uncovered and visible from the doorways of their rooms. Findings include: Review of the facility policy titled Resident Rights review date October 2016 revealed under Facility Responsibilities: The facility Must: 1. Treat residents with respect and dignity and provide care and services for the residents in a manner and in an environment that promotes maintenance or enhancement of the resident's quality of life and protect and promote the resident's rights. 1.Review of the electronic medical record (EMR) for R26 revealed a [AGE] year-old male admitted to the facility with diagnoses to include Alzheimer's disease, dementia with behavioral disturbance, and acute failure, and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment, and no behaviors. In addition, R26 was documented as always incontinent of bladder and bowel. The Care Plan for R26, dated 10/13/2023, revealed a Foley catheter was placed related to urinary retention. The list of interventions did not include covering and placement of the urinary catheter to protect the dignity of residents. Review of the Physician Orders dated 10/16/2023 revealed an order for Foley catheter related to urinary retention. Observations of R26 on 12/5/2023 at 2:14 pm, 12/6/2023 at 9:55 am, and 12/6/2023 at 10:25 am, revealed R26 had a urinary catheter with an uncovered drainage bag which was visible from the doorway. Review of the EMR for R45 revealed an [AGE] year-old female admitted to the facility with diagnoses to include fracture of unspecified part of neck of right femur, edema, and pressure-induced deep tissue damage of sacral region. Review of the annual MDS assessment dated [DATE] documented a BIMS score of 99, indicating the score could not be calculated due to severely impaired cognition, a Mood score of 0, indicating no depression, and no behaviors. In addition, she had an indwelling urinary catheter and was always incontinent of bowel. Review of the Care Plan for R45, dated 9/1/2023, revealed a Foley catheter was placed related to wound healing and high risk for urinary tract infection. Review of the interventions did not include covering and placement of the urinary catheter bag for the protection of the resident's dignity. Review of the Physician's Orders for R45 revealed an order for a urinary catheter dated 8/24/2023. Observations of R45 on 12/5/2023 at 2:03 pm, 12/6/2023 at 9:54 am, and 12/6/2023 at 10:25 am, revealed the urinary catheter drainage bag was uncovered and visible from the doorway. In an interview with 12/6/2023 at 10:25 am, with Certified Nursing Assistant (CNA) GG stated the urinary catheter drainage bag should be covered with privacy bag at all times. In an observation/interview on 12/6/2023 at 10:30 am, with CNA HH and CNA JJ they each stated the urinary catheter drainage bags should be covered by privacy bags and positioned where they are not visible from the doorway. Each CNA confirmed the catheter for R26 and R45 were uncovered and exposed to the doorway. In an observation/interview on 12/06/23 at 10:45 am, with Licensed Practical Nurse (LPN) II she confirmed the catheter drainage bags for R26 and R45 were uncovered and exposed to the doorway. She stated they don't usually place a privacy bag unless the resident gets out of bed, especially if the door is closed and the curtain is pulled. 46578 2.Findings include: During multiple observations on 12/5/2023 at 10:45 am and 4:05 pm, on 12/6/2023 at 9:20 am, Resident (R)280's catheter bag was hooked onto the side of his bed with no privacy cover. A review of the electronic medical record (EMR) revealed R280 a male who was admitted to the facility on [DATE] with diagnoses of, but was not limited to, retention of urine, orthopedic aftercare, and hypertension. A review of R280 Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, which indicates R280 was cognitively intact; Section GG, function status revealed R280 is independent for upper body activity and requires supervision/touching assistance for lower body activity. Interview on 12/06/2023 at 10:25 am with Certified Nursing Assistant (CNA) BB stated catheter bag should be always covered in privacy bag. Interview on 12/7/2023 at 3:30 pm with Licensed Practical Nurse (LPN) AA revealed residents with a urinary catheter should have a privacy cover on the bag.

Based on staff and physician interviews, record review, review of the facility documents and procedural guidelines titled, Medical Director Employment Agreement, Physician Services - The Medical Director's Role and Responsibilities, and Professional Staff Application - Staff Responsibilities, the facility failed to follow the current Centers for Medicare and Medicaid Services (CMS) regulations in regard to the frequency of physician visits for residents in nursing homes for one of 124 residents (R118). The deficient practice had the potential to prevent R118 from receiving the required level of care delivered by the facility. Finding include: Review of the facility's procedural guidelines titled Physician Services the Medical Director's Role and Responsibilities under Intent:15. Assist the facility in the assurance that physician services are in compliance with current rules, regulations, and long-term guidelines. Review of facility documents titled, Medical Director Employment Agreement signed by Doctor (Dr FF), on 4/27/2015 to begin on 5/1/2015 revealed on page three 8. The Physician agrees to comply and provide all necessary documentation on completion of the medical records within acceptable time limits. Review of the facility document titled, Professional Staff Application - Staff Responsibilities signed by Dr. FF revealed under Staff Responsibilities: The professional agrees to; 7. As attending physician, visit residents, in accordance with state and federal regulations, at least once every thirty (30) days for skilled residents and for intermediate care residents thereafter. During each visit, the Staff Physician will: a.) Personally visit and review the resident's total program of care, including medications and treatments. On 12/7/2023 at 6:52 pm. Dr. FF hand delivered two history and physical documents for R118's admissions to the facility on [DATE] and 9/8/2023. He revealed he had not seen or written any other notations on R118's since her admission on 9/8/2023. Interview On 12/7/2023 at 6:52 pm. with Dr. FF revealed he had been the Medical Director of the facility for many years and is the primary physician for all residents in the facility. He revealed he has never routinely rounded on residents or documented a progress note on them. He stated that he completes and documents the history and physical on new resident admissions and assesses residents when needed, which is rare. Dr. FF revealed the Nurse Practitioner (NP) does all the rounding and documentation on the residents in the facility after the initial history and physical is completed by him. Continued interview revealed that when he agreed to be the Medical Director for the facility, he was assured that he would only need to see residents upon admission, and that his NP would be able round on all residents the remainder of their stay unless something came up the NP needed assistance, or in emergency situations. Further interview also revealed that he was not familiar with the federal regulation that required the physician to assess and document residents every thirty days for the first 90 days after admission and then at least once every 60 days thereafter. He stated that he had never been told that and wasn't aware of this regulation. On 12/7/2023 at 7:09 pm. the administrator presented the surveyor a letter from the Georgia Department of Health titled RE: Physician Delegation in Nursing Homes dated 3/1/2012, and a copy of a memorandum from the Centers for Medicare and Medicaid Services dated 11/13/2003 with the subject line Physician Delegation of Tasks in Skilled Nursing Facilities (SNFs) and Nursing Facilities (NF). The Administrator shared that they were under the impression that these waivers exempted them from the current physician frequency visits listed in the CMS guidelines for long term facilities.

Based on staff and physician interviews, record review, review of facility documentation, and a review of the facility procedural guidance titled, Credentialing of Professional Staff, the facility failed to ensure one of 124 residents (R118) had complete access to the resident's medical record which is necessary to care for residents in a safe effective manner. The deficient practice had the potential to hinder the ability of all staff to deliver unfragmented resident care. Findings include: Review of the facility's procedural guidelines titled, Credentialing of Professional Staff last revised on December 2012 revealed under Staff Responsibilities: The Professional Agrees to 10. Write, sign and date progress notes descriptive on the resident's condition in a timely manner. Under Facility Responsibilities: The Facility shall be responsible for: 1. Assuring that the Staff Professional has complete access to all records and supplies within the Facility necessary for the performance of his/her duties. Under Charting Intent: It is the intent of Magnolia Manor facilities that all services provided to the resident or any changes I the resident's condition is recorded in the resident's medical records. Procedural Guidelines: 1. Pertinent observations, medications given, services performed, etc., should be recorded in the resident's chart. 2. All incidents, accidents, or changes in the resident's condition should be recorded. Under Progress Notes -Procedural Guidelines: 2. Progress notes reflect the resident's current status and response to his/her care plan, medications, diet, etc. 4. Progress notes address significant change in resident condition (physical or behavioral/emotional) and response to programs. Under Charting and Documentation: 2. Incidents accidents or changes in the resident's condition shall be recorded. Interview on 12/7/2023 at 6:38 pm with the Administrator revealed that neither the physician or midlevel associated with the physician documented in the electronic medical record used by the facility, all notes are written on paper. R118 was admitted to the facility's Memory Care Unit on 9/8/2023 but she could not locate the history and physical or any progress notes, on paper or electronic form since admission. She revealed Dr FF's handwritten progress notes are not made available to the facility until billing is submitted for the visit and are then forwarded to the facility to be scanned into the medical record. The Administrator revealed they do not have access to a copy of Dr. FF's or Nurse Practitioner's (NP) documentation for reference until the paper documents are forwarded to the facility for scanning. Interview on 12/7/2023 at 6:52 pm. with Doctor (Dr FF) revealed he had been the Medical Director of the facility for many years and is the primary physician for all residents in the facility. Dr. FF revealed he does not use electronic medical records and handwrites everything. He stated that after documenting, he takes his notes with him for billing, and then returns the documents to the facility for scanning into medical record. On 12/8/2023, the Administrator e-mailed surveyor the NP's progress notes unavailable at time of survey for R118 since her 9/8/2023 admission to the facility. These notes were dated 10/26/2023 and 11/27/2023 and handwritten on paper. Record review of Nursing Progress Notes revealed that on 11/16/2023 at 1:10 pm, the NP was notified of a change in R118's status, a fingerstick blood glucose level was obtained with a result of HI, indicating the blood sugar was higher than the glucometer could read. The NP then ordered to send R118 to the emergency room for evaluation and was subsequently admitted to the hospital. R118 was hospitalized [DATE] through 11/20/2023. No provider documentation regarding this specific significant change in status was present in the medical record or mentioned in the subsequent NP progress note dated 11/27/2023 except the notation hospital returned.

Based on observations, staff interviews, record reviews, and a review of the facility's policy titled, Infection Prevention and Control, the facility failed to maintain infection control standard precautions by, not keeping a nebulizer mask and Continuous Positive Airway Pressure (CPAP) nasal cushions enclosed inside a bag when not in use for two of 18 Residents (R) R99 and R112. Findings Include: 1. Review of the facility policy titled, Infection Prevention and Control last revised and approved February 2020 revealed, the intent of Magnolia Manor facilities is to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and prevent the development and transmission of disease and infection. Observations on 12/5/2023 at10:25 am, 12/6/2023 at 9:15 am, and 12/7/2023 at 11:45 am R99's nebulizer machine is sitting on the bed-side table with the reusable mask lying on top of the machine, not secured in a dated and labeled bag. Record review revealed resident was admitted to the facility with a diagnosis including but not limited to Cerebral Infarction and hypertension. Review of R99 five-day Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of four, which indicates severe cognitive impairment. Section GG (functional status) revealed she is dependent on others for all Activities of Daily Living (ADLS) and physical activity. Review of R99's Physician Orders List revealed R99 has been ordered breathing treatments of Ipratropium four times per day as needed for shortness of breath. A review of the Electronic Medication Administration Record (EMAR) revealed she received breathing treatments four times a day from November 15th through the 30th and one time at 8:00 am on December 1, 2023. Interview on 12/6/2023 at 4:00 pm with Certified Nursing Assistant (CNA) BB revealed respiratory equipment not being used should be kept in a dated bag. Interview on 12/7/2023 at 3:30 pm with Licensed Practical Nurse (LPN) AA revealed nebulizer mask should be in a bag with the resident's name and a date, when not in use. Interview on 12/07/2023 at 9:46 am with the Director of Nursing (DON) revealed, that they do not have respiratory therapists on staff, nursing sets up, administers, and maintains all respiratory treatments and equipment. She also confirmed that all oxygen equipment such as nasal cannulas, CPAP masks and nasal cushions and nebulizer mask/equipment must be covered when not in use. 47948 2.Findings include: Record review for R112 revealed resident was admitted to the facility with a diagnosis including but not limited to sleep apnea. Review of Physician Orders List revealed R112 had been ordered to apply her Continuous Positive Airway Pressure (CPAP) machine at bedtime. A review of the Electronic Medication Administration Record (EMAR) revealed a nursing measure for staff to apply R112's CPAP at bedtime and was timed for 8:00 pm each evening. Observation on 12/05/23 at 10:30am, R112 was found to not be present in her room. The CPAP machine with tubing and nasal cushions was observed lying on the bedside table, not in use, and not in a protective covering. Observation on 12/6/2023 at 9:11 am. revealed R112 lying supine in bed with eyes closed. The CPAP tubing and nasal cushions were observed lying on the bedside table, not in use, and not covered.

Based on observations, and interviews, it was determined that the facility failed to maintain a comfortable interior related to temperatures in rooms and a common area on one of four units (the secure unit: 400 Unit). This failure affected one of four units related to comfortable temperature in the resident's room and common area. Findings include: Review of the facility records revealed that the resident on 400 secure unit were not interviewable. During an observation on 9/16/2021 at 1:20 p.m. on the 400 secure unit on the wall next to the nursing station, the thermostat display read 69 degrees Fahrenheit. And sitting in the common area in front of the nursing station were 15 residents. Three residents were wearing sweaters/jacket; seven residents were wearing long sleeves shirt; one resident has on two shirts and four residents were wearing short sleeve shirts. An observation on 9/16/2021 at 3:42 p.m. on the 400 secure unit the thermostat display read 70 degrees. An observation on 9/16/2021 at 3:45 p.m. in room 421 revealed that the room was cold. The air unit on the wall did not have a self-adjustment switch on the wall. An observation on 9/20/2021 at 12:10 p.m. revealed 13 residents in the common area wearing long sleeve shirts and three of them were wearing sweaters. An observation on 9/20/2021 at 12:12 p.m. revealed R#3 lying in her bed with a thin dark blue sheetlike material draped over her. She was in a curled fetal position saying she was cold. The following observations were conducted with the Maintenance Director. The temperatures were obtained using a laser temperature device: An observation on 9/20/2021 at 3:28 p.m. observed room 422, the room air reading was at 68 degrees. The air conditioner air flow from the vent read 68 degrees. An observation on 9/20/2021 at 3:29 p.m. observed room 423, the room air reading was 64 degrees. The air condition air flow from the vent read 55 degrees. An observation on 9/20/2021 at 3:30 p.m. observed in room 421, the room air reading was 67 degrees. The air condition was not working properly, and the air flow vent read 68.5 degrees. An observation on 9/20/2021 at 3:31 p.m. observed in room 432, the room air reading was 68.5 degrees. The air condition was not working, and the air flow vent read 69.5 degrees. An observation on 9/20/2021 at 3:32 p.m. observed in room 436, the room air reading was 68.5 degrees. The air flow vent reading was 69 degrees. An observation on 9/20/2021 at 3:34 p.m. observed in room 439, the room air reading was 68.0 degrees. The air flow vent reading was 69 degrees. During an interview on 9/20/2021 at 3:40 p.m. the Maintenance Director revealed that residents individual rooms have a remote control to adjust the temperature in the room. The nurses have the remote control to change the temperature in the rooms. During an interview on 9/20/2021 at 5:21 p.m. the Administrator revealed that the air conditioner contractor had been contact about the air conditioner unit that tripped off. The Administrator showed an email dated for 9/20/2021 address to the (named vendor) air conditioner. She stated that she was not sure of regulation requirements for resident's room. And that the maintenance director had conveyed to her that he did not maintain a room temperature log for the residents' room.

Based on interview and policy review, the facility failed to ensure a qualified Infection Preventionist was on staff at the facility, creating the potential for an ineffective infection prevention program and contributing to the spread of COVID-19 for all residents in the facility. Findings include: Review of the facility's policy titled, Infection Preventionist revised July 2016, revealed, .The Infection Preventionist is responsible for coordinating the implementation and updating of our established infection prevention and control policies and practices. The policy did not specify that the Infection Preventionist was required to work at least part-time in the facility or required any specialized training. Interview on 12/02/20 at 10:00 a.m., the facility's Assistant Administrator identified Infection Preventionist (IP) and the Director of Nursing (DON) as the person responsible for coordinating the implementation and updating the facility's infection control practices. During an interview on 12/02/20 at 3:23 p.m., the DON stated the facility's previous IP Nurse left the facility in October 2019 and since then she and the IP has been in transition to fill the position but did not complete the course. The DON confirmed no one at the facility has completed the Infection Preventionist program.

Based on staff interviews, record review, and review of the facility's policy and Centers for Disease Control and Prevention (CDC) guidance, the facility failed to follow the CDC guidelines for the administration of pneumococcal vaccines for two of five residents (Resident (R) 4 and R5) reviewed for immunizations. Findings include: 1. Review of R4's face sheet, found in the medical record, revealed the resident had been re-admitted to the facility on [DATE]. Review of the annual Minimum Data Set (MDS), dated [DATE], coded the resident's Pneumococcal vaccination as up to date. Further review of R4s Resident Immunization Record revealed there was no documentation of resident being offered and refusing or having received the Pneumococcal vaccination. Interview with the Direction of Nursing (DON) on 12/02/20 at 3:30 PM, the DON stated the resident was not offered the vaccine upon admission due to his age but should have been offered the vaccine this year. The DON stated if the resident refused the vaccine it would be documented on the Immunization Record or in the progress notes. 2. Review of R5's face sheet, found in the medical record, revealed the resident was admitted to the facility on [DATE]. Review of the resident's quarterly MDS, dated [DATE], coded the resident's Pneumococcal vaccination as up to date. Further review of R5's Resident Immunization Record revealed there was no documentation of resident being offered and refusing or having received the Pneumococcal vaccination. Interview with the MDS Coordinator on 12/02/20 at 4:13 PM, the MDS Coordinator stated that she could not find documentation that R5 was offered the Pneumococcal vaccine. During an interview on 12/02/20 at 5:03 PM, the Assistant Administrator confirmed documentation of the residents being offered the vaccine and/or refusing the vaccine was not documented in the residents' medical record. Review of the CDC Guidance titled, Pneumococcal Vaccination Recommendations indicated, CDC recommends routine administration of pneumococcal [MEDICATION NAME] vaccine (PPSV23) for all adults [AGE] years or older. Review of the undated facility's policy titled Pneumococcal Vaccine indicated, .2. Assessments of the pneumococcal vaccination status will be conducted within five (5) days working days of the resident's admission if not conducted prior to admission . 4. Pneumococcal vaccines with be administered to residents (unless .already given, or refused) .5 .If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal .6. For residents who receive the vaccine, the date of the vaccination, lot number, expiration date, person administering, and site of vaccination will be documented in the residents medical record.

Based on interview and record review, the facility failed to ensure that medication for pain was administered for one of 12 residents(A) and failed to provide wound care for one of 12 residents (B) as care planned. Findings include: 1. During interviews on 6/3/19 at 12:00 p.m. and 6/4/19 at 1:50 p.m. Resident (R) A stated that nursing staff waits until her pain medication runs out to order more. Record review revealed that RA had a care plan since 2/819 for being at risk for alteration in comfort related to [MEDICAL CONDITION] reflux disease, generalized pain and skin alteration. The care plan included an intervention for licensed nursing staff to administer medication as ordered. Further record review revealed that there was a physician's orders [REDACTED]. There was also a physician's orders [REDACTED]. However, a review of the clinical record revealed that the resident did not receive the scheduled [MEDICATION NAME] pain medication as ordered and as care planned on 4/23/19 at 12:00 p.m. and 6:00 p.m. Record revealed that on 5/24/19 a physician's orders [REDACTED]. The resident received [MEDICATION NAME] as scheduled through the 5/24/19 6:00 p.m. dose. The [MEDICATION NAME] 10-325mg was then administered routinely afterward until the supply on hand was exhausted on 5/29/19 at 6:00 p.m. Therefore, the resident did not receive the scheduled [MEDICATION NAME] pain medication as ordered and as care planned on 5/30/19 at 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. Cross refer to F697 2. Record review revealed that RB had a care plan problem, dated 4/2/19, for receiving treatment with an antibiotic for bilateral [MEDICAL CONDITION]. The care plan problem was updated on 4/29/19 to include the use of an intravenous antibiotic and an intervention for nursing staff to provide wound care as ordered. A review of the clinical record revealed a physician's orders [REDACTED]. This treatment was ordered to treat venous wounds to the right and left lateral calves. During an interview on 6/5/19 at 3:45 p.m. R B stated that Treatment Nurse DD had applied a silver alginate dressing to her legs and she was not supposed to. During interviews on 6/6/19 at 4:00 p.m. and 6/7/19 at 10:45 a.m., Treatment Nurse DD confirmed that she had applied [MEDICATION NAME] Ag, which contains silver, to the open areas on the resident's lower extremities, one day prior to a visit to the wound clinic in (MONTH) 2019, to try something different to help the resident because she was upset about her legs. Treatment nurse DD confirmed that she did not obtain a physician's orders [REDACTED]. A review of wound clinic notes from 5/10/19 confirmed RB reporting the use of silver dressings to her lower extremity wounds. Cross refer to F684

Based on interview and record review, the facility failed to ensure that wound treatments were provided as ordered by the physician for one of 12 residents (R B). Findings include: Record review revealed that Resident (R) B had [DIAGNOSES REDACTED]. During an interview on 6/5/19 at 3:45 p.m. R B stated that Treatment Nurse DD had applied a silver alginate dressing to her legs and she was not supposed to. A review of the clinical record revealed a physician's orders [REDACTED]. This treatment was ordered to treat venous wounds to the right and left lateral calves. During an interviews on 6/6/19 at 4:00 p.m. and 6/7/19 at 10:45 a.m., with Treatment Nurse DD confirmed that she had applied [MEDICATION NAME] Ag, which contains silver, to the open areas on the resident's lower extremities, one day prior to a visit to the wound clinic in (MONTH) 2019, to try something different to help the resident because she was upset about her legs. Treatment nurse DD confirmed that she did not obtain a physician's orders [REDACTED]. A review of wound clinic notes dared 5/10/19 confirmed that RB reported the use of silver dressings to her lower extremity wounds. During an interview on 6/7/19 at 12:55 a.m., with the Director of Nursing (DON) revealed that she expected licensed nursing staff to obtain a physician's orders [REDACTED].

Based on interview, record review, and review of the facility policy titled, Obtaining and Receiving Medications from Pharmacy the facility failed to ensure the medication for pain was obtained timely for one of 12 residents (R A). Findings include: The facility had an Obtaining and Receiving Medications from Pharmacy policy. The policy documented that medications that must be reordered by the nurse included controlled substance medications. The policy further documented that Schedule II medications such as [MEDICATION NAME] and [MEDICATION NAME] products required a signed prescription by the physician and should be reordered at least seven days in advance. During interviews on 6/3/19 at 12:00 p.m. and 6/4/19 at 1:50 p.m. Resident (R) A stated that nursing staff waited until her pain medication ran out to order more. Record review revealed that RA had a care plan since 2/8/19 for being at risk for alteration in comfort related to [MEDICAL CONDITION] reflux disease, generalized pain and skin alteration with an intervention for licensed nursing staff to administer medication as ordered. Further record review revealed a Physician's order since 2/15/19 for [MEDICATION NAME] 10-325 milligrams (mg) to be administered every six hours for pain. There was also a physician's order since 2/13/19 for [MEDICATION NAME] 10-325 mg to be administered every six hours as needed for pain. However, a review of the clinical record revealed that the resident did not receive the scheduled [MEDICATION NAME] pain medication as ordered and as care planned on 4/23/19 at 12:00 p.m. and 6:00 p.m. On 4/23/19 a Physician's order was obtained to 1) Hold [MEDICATION NAME] 10-325 mg every six hours and resume when it was available. 2) Administer [MEDICATION NAME] 10-325 mg every six hours, scheduled and discontinue when the [MEDICATION NAME] became available. 3) Keep the order for [MEDICATION NAME] 10-325 mg every six hours as needed for pain. A review of the (MONTH) 2019 Medication Administration Record [REDACTED]. On 5/24/19 a Physician's order was again written to 1) Hold [MEDICATION NAME] 10-325 mg every six hours and resume when available 2) Administer [MEDICATION NAME] 10-325mg every six hours, scheduled, for pain and discontinue when [MEDICATION NAME] is available. The resident received [MEDICATION NAME] as scheduled through the 5/24/19 6:00 p.m. dose. The [MEDICATION NAME] 10-325mg was then administered routinely afterward until the supply on hand was exhausted on 5/29/19 at 6:00 p.m. When the on-hand supply of [MEDICATION NAME] 10-325 mg was exhausted, the [MEDICATION NAME] still had not been obtained from the pharmacy. During an interview on 6/3/19 at 12:40 p.m., Licensed Practical Nurse (LPN) AA stated that she phoned the pharmacy on the morning of 5/29/19 (a Wednesday) to check on the status of the [MEDICATION NAME] because she only had two doses of the [MEDICATION NAME] (for 12:00 p.m. and 6:00 p.m.) remaining. LPN AA stated that the pharmacy said they were waiting on a physician signature to fill the prescription. A new Physician's order was obtained on 5/30/19 to administer one Tylenol #4 every six hours as needed until the [MEDICATION NAME] arrived from the pharmacy. A review of the (MONTH) 2019 MAR's and narcotic logs revealed that the resident did not receive the Tylenol #4 until 12:30 a.m. on 5/31/19. Therefore, after the on-hand supply of [MEDICATION NAME] was exhausted and prior to obtaining and receiving the Tylenol #4 medication, the resident missed four scheduled [MEDICATION NAME] pain medication doses on 5/30/19 at 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. During an interview on 6/3/19 at 1:40 p.m. the Director of Nursing (DON) stated that the nurses should be checking and following up on medications that are low at the beginning of the week.

Based on record review, observation, Incident/Accident Report review, and staff interview, it was determined that the facility failed to ensure that one (1) resident (#1) received supervision and Hoyer lift transfer, as specified by the Care Plan, and failed to use floor mats as specified by the Care Plan for one (1) resident (#4), from a survey sample of six (6) residents. Resident #1 fell and sustained a [MEDICAL CONDITION] leg. Findings include: 1. Cross refer to F323, Example 1, for more information regarding Resident #1. Clinical record review for Resident #1 revealed a Care Plan entry of 02/24/2010 which identified the resident to be at risk for falls, with Approaches which included the use of a Hoyer lift for all transfers and to monitor/anticipate/intervene for factors causing falls. A Nurse's Notes entry of 02/01/2011 at 2:50 p.m. documented that the nurse observed the resident on the floor in the room after having fallen while being changed. The resident complained of right knee pain, and swelling was noted to the right knee and thigh. A Nurse's Notes entry of 02/01/2011 at 3:00 p.m. documented that the physician was notified and ordered a hospital transfer, and a Nurse's Notes entry of 02/01/2011 at 7:00 p.m. documented that the resident had been admitted to the hospital with [REDACTED]. A 02/01/2011 facility Incident/Accident Report documented that Nursing Assistant In Training "AA" had been providing incontinence care to Resident #1 at the sink and then slid the resident to the floor. The resident sustained [REDACTED]. During an interview with Nursing Assistant In Training "AA" conducted on 03/02/2011 at 4:10 p.m., the nursing assistant stated she had been working by herself when providing care to Resident #1. In a written statement provided by the Director of Nursing (DON), the DON documented that Resident #1 had been transferred by Nursing Assistant "AA" without the use of a mechanical lift (as specified in the Care Plan), and that additional certified nursing assistant staff had failed to aid and assist Nursing Assistant in Training "AA" while transferring and providing incontinence care to Resident #1 (to ensure the appropriate monitoring and intervention for factors causing falls, per the Care Plan). Based on the above, the facility failed to ensure that staff monitored and provided the necessary intervention, per the Care Plan, to Resident #1 to minimize the fall potential while receiving care, and failed ensure that the resident was transferred with the use of a Hoyer lift, as specified by the Care Plan. 2. Cross refer to F323, Example 2, for more information regarding Resident #4. Record review for Resident #4 revealed a 05/19/2010 Care Plan entry which specified the use of soft floor mats for fall precautions. Observations on 03/21/2011 at 3:12 p.m. and 3:35 p.m. revealed no floor mats on either side of the resident's bed.

Based on record review, observation, Incident/Accident Report review, and staff interview, it was determined that the facility failed to ensure that one (1) resident (#1) received the necessary supervision, and Hoyer lift transfer, as specified by the Care Plan to minimize the risk of a fall for one (1) resident (#1), and failed to use floor mats as specified by the Care Plan to serve as a fall precaution for one (1) resident (#4), from a survey sample of six (6) residents who had been assessed as being at risk for falls. Resident #1 subsequently fell and sustained a fracture of the right leg. Findings include: 1. Clinical record review for Resident #1 revealed a record Face Sheet which documented that the resident had [DIAGNOSES REDACTED]. A Care Plan entry of 02/24/2010 identified the resident to be at risk for falls, with Approaches to address this risk which included to monitor/anticipate/intervene for factors causing falls. A Nurse's Notes entry of 02/01/2011 at 2:50 p.m. documented that the licensed nurse had been called to the resident's room by a nursing assistant and observed the resident to be sitting on the floor in the room. This Note documented that the resident had fallen while being changed, and that the resident complained of right knee pain, with swelling noted to the right knee and thigh. A Nurse's Notes entry of 02/01/2011 at 3:00 p.m. documented that the physician was notified of the resident's condition, and that an order was received to send the resident to the hospital for evaluation. A Nurse's Notes entry of 02/01/2011 at 3:40 p.m. documented that Emergency Medical Services had arrived to transport the resident to the hospital, and a Nurse's Notes entry of 02/01/2011 at 7:00 p.m. documented that the resident had been admitted to the hospital with [REDACTED]. A 02/01/2011 facility Incident/Accident Report which referenced Resident #1's fall documented that Nursing Assistant In Training "AA" had been providing incontinence care to Resident #1 at the sink, but the resident was unable to hold on and Nursing Assistant "AA" thus slid the resident to the floor. This resulted in the resident sustaining a fracture of the right distal femur. Review of the Corrective Counseling Statement of 02/02/2011, completed as part of the facility's investigative intervention related to this accident involving Resident #1, revealed documentation specifying that this resident was of a no-weight-bearing status, but that the nursing assistant had stood the resident up at the sink to provide incontinence care. In a written statement dated 02/01/2011, Nursing Assistant In Training "AA" documented that when Resident #1 needed a changed brief, the Nursing Assistant in-training asked supervisory Nurse "CC" the way of changing the resident, and was told to ask a certified nursing assistant the usual routine. Nursing Assistant "AA" documented that she then asked Certified Nursing Assistant (CNA) "DD" the proper procedure for providing incontinence care to Resident #1, and that CNA "DD" stated the resident could assist and hold herself at the sink with support. Nursing Assistant In Training "AA" further documented that she assisted the resident to the sink, but that during the process of providing incontinence care, the resident let go of the sink and the nursing assistant slid the resident to the floor. During an interview with Nursing Assistant In Training "AA" conducted on 03/02/2011 at 4:10 p.m., the nursing assistant acknowledged that she had been working by herself when providing care to Resident #1 on the date of the resident's fall. Nursing Assistant In Training "AA" also acknowledged that she had been unsure if Resident #1 was to be changed in bed or assisted to the bathroom for incontinence care. Further record review for Resident #1 revealed that the Care Plan entry of 02/24/2010 addressing the resident's risk for falls also referenced an Approach to use a Hoyer lift for all transfers. The nursing assistant's activities of daily living plan of care for this resident specified the use of a two (2) person Hoyer lift only. In a written statement provided by the Director of Nursing (DON), the DON documented that she had interviewed Nurse "CC", CNA "DD", and also CNA "EE". The DON documented that Resident #1 had been transferred by Nursing Assistant "AA" without the use of a mechanical lift. This statement also documented that the resident had fallen and had sustained a fractured leg. The DON further documented that CNA "DD" had admitted that she did not accompany or instruct Nursing Assistant In Training "AA" on how to lift Resident #1, documented that neither CNA "DD" or CNA "EE" were present when the resident fell , and documented that both CNAs had a responsibility to aid and assist Nursing Assistant In Training "AA" while she was in her orientation phase. During an interview with the DON on 03/02/2011 at 2:55 p.m., the DON acknowledged that Nursing Assistant In Training "AA" had attempted to change the resident by standing her up without assistance. The DON also acknowledged that the CNA had transferred the resident without assistance and without using the Hoyer lift, even though the Care Plan specified the use of a Hoyer lift for transfers. Based on the above, the facility failed to ensure that Resident #1, who had [DIAGNOSES REDACTED]. The facility also failed to ensure that the resident was transferred with the use of a Hoyer lift, as specified by the Care Plan. 2. Record review for Resident #4 revealed a 05/19/2010 Care Plan entry identifying the resident's fall potential due to poor endurance, tiring easily and unsteady gait. This Care Plan specified an intervention to place soft floor mats for fall precautions. However, observations of the resident on 03/21/2011 at 3:12 p.m. and 3:35 p.m. revealed that the resident was on the bed, with no floor mats on either side of the bed for fall precautions.

Based on record review, Incident/Accident Report review, and staff interview, the facility failed to ensure that a nursing assistant had demonstrated competency and had been determined competent in the provision of care before allowing the nursing assistant in training to transfer and provide incontinence care for one (1) resident (#1) from a survey sample of six (6) residents. This failure resulted in actual harm ([MEDICAL CONDITION] leg) for Resident #1. Findings include: Cross refer to F323 for more information regarding Resident #1. Clinical record review for Resident #1 revealed a Care Plan entry of 02/24/2010 which identified the resident to be at risk for falls and included the use of a Hoyer lift for all transfers, as well as to monitor/anticipate/intervene for factors causing falls. A Nurse's Notes entry of 02/01/2011 at 2:50 p.m. documented that the licensed nurse had been called to the resident's room and observed the resident sitting on the floor in the room, after having fallen while being changed. This Note documented that the resident complained of right knee pain, with swelling noted to the right knee and thigh, and that an order was received to send the resident to the hospital for evaluation. A Nurse's Notes entry of 02/01/2011 at 3:40 p.m. documented that the resident was transported to the hospital, and a Nurse's Notes entry of 02/01/2011 at 7:00 p.m. documented that the resident had a [DIAGNOSES REDACTED]. A 02/01/2011 facility Incident/Accident Report which referenced Resident #1's fall documented that Nursing Assistant In Training "AA" had been providing incontinence care to Resident #1 at the sink, but the resident was unable to hold on and Nursing Assistant "AA" thus slid the resident to the floor. This resulted in the resident sustaining a [MEDICAL CONDITION] distal femur. In a written statement dated 02/01/2011, Nursing Assistant In Training "AA" documented that when Resident #1 needed a changed brief, she assisted the resident to the sink, but that during the process of providing incontinence care, the resident let go of the sink and the nursing assistant slid the resident to the floor. During an interview with Nursing Assistant In Training "AA" conducted on 03/02/2011 at 4:10 p.m., the nursing assistant acknowledged that she had been working by herself when the resident experienced the fall, further stating that she was still in orientation at the facility and had not completed the competency testing portion of the nurse aide training at the time of the accident. In a written statement provided by the Director of Nursing (DON), the DON documented that Resident #1 had been transferred by Nursing Assistant "AA" without the use of a mechanical lift, had fallen and had sustained a fractured leg. The DON further documented that Nursing Assistant In Training "AA" was still in her orientation phase at the time of Resident #1's fall. Review of the personnel file for Nursing Assistant In Training "AA" revealed the nursing assistant had completed an accredited class for nurse aide training; however, she had not been tested for competency to be placed on the state registry for a certified nursing assistants. Nursing Assistant In Training "AA" was allowed to provide care unassisted to Resident #1 on 02/01/2011, even though review of a C.N.A. Clinical Skills Evaluation Skills Update sheet revealed that Nursing Assistant "AA" was not checked as being able to perform tasks independently, including resident safety and the use of mechanical lifts, until 02/22/2011.