Every finding on record at Marian Manor Healthcare Center

1.Based on observation, record review, review of the facility investigation, review of facility policy, review of professional reference, and resident, resident representative, and staff interviews, the facility failed to provide appropriate supervision for 1 of 1 sampled resident (Resident #3) who experienced a choking episode. Failure of staff to remove snack items not on Resident #3's ordered diet from the resident's room and ensure all foods served follow the resident's mechanically altered diet order resulted in Resident #3 experiencing a choking episode and hospitalization and placed all residents on mechanically altered diets at risk for injury. During the standard survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 02/17/26 at 11:30 a.m. The IJ resulted when the staff failed to remove snack items not consistent with Resident #3's mechanically altered diet order from the resident's room which resulted in Resident #3 experiencing a choking episode and hospitalization.*05/26/26 at 7:20 p.m., the survey team notified the Administrator and Director of Nursing (DON) of the IJ situation, provided the IJ template, and requested the facility's removal plan for the IJ. *05/27/26 at 4:00 p.m., the SSA reviewed and accepted the facility's removal plan for the IJ. The removal plan contained the following:*All care plans/certified nurse aide (CNA) door cards of residents with mechanically altered diets were reviewed and updated per current orders. *Electronic meal charting screens in the electronic medical record (EMR) were reviewed and updated so all residents' diet orders are visible for staff.*Educational reference posters regarding altered diet levels (International Dysphagia Diet Standardisation Initiative) (IDDSI) placed in all nurses' stations and central station for staff to refer to. *CNAs and nurses were sent a memo via EMR informing them of the above information. *Office manager sent an electronic memo to all resident representatives/power of attorneys (POA) stating the following: Please be aware of your loved one's diet orders when bringing snacks and foods from home. This includes consistency of liquids and texture of foods that could potentially cause an increased risk of choking. Please notify your family members of this. *A form was added to the admission packet to notify representatives/POAs.*Dietary Supervisor obtained a food chopper to assure bite sized pieces are cut prior to serving residents. *Education provided to dietary personnel to assure any meal for any resident with mechanically altered diet is prepared according to their specific diet before leaving the serving window. *Dietary Supervisor contacted both the Speech Therapist and Dietician about a training possibility for nursing and dietary staff to be held at a future date. *Tray cards implemented for all residents for all meals. *05/27/26 at 6:00 p.m., the survey team verified the implementation of the removal plan. The deficient practice remained at a G scope and severity following the removal of the IJ.Findings include:Review of the facility policy titled Dietary Services occurred on 05/28/26. This undated policy stated, . The food and nutritional needs of residents will be met in accordance with the physician's orders . Therapeutic diets will be prepared and served as prescribed by the physician . Meals are planned, prepared, and supervised by knowledgeable persons . Food is prepared . in forms to meet individual needs, such as cutting, grinding, chopping, and pureeing, etc.Review of the Complete IDDSI Framework accessed at iddsi.org, dated April 2026, stated, . describe texture modified foods . used for individuals with dysphagia [difficulty swallowing] . level 6 soft & [and] bite - sized . 'Bite-sized' pieces . Adults . 1.5 cm [centimeters] pieces (no larger than) . Food Textures That [NAME] A Choking Risk . Chewy textures are a choking risk because they are sticky and can become stuck on the roof of the mouth, the teeth or cheeks and fall into the airway. Examples of chewy textures: . marshmallows .Review of Resident #3's medical record occurred on all days of survey and identified intact cognition. Diagnoses included dementia, cleft palate (opening or split in the roof of the mouth), and dysphagia. A speech therapy SNF [skilled nursing facility] Daily Note, dated 09/24/25, stated, . long history of dysphagia and recurrent hospitalizations. recommend an IDDSI Level 6 diet (Soft and Bite-Sized) . This was discussed with dietary staff and nursing who verbalized understanding. The care plan stated, . I have a dx [diagnosis] of Dysphagia . I am at risk of aspiration [breathing food, liquid, saliva, or vomit into airway and lungs] and choking . Mechanically altered consistency . Level 6 soft and bite sized Original Order Date: 09/24/2025 .A nurse's note, dated, 02/17/26 at 12:54 p.m., stated, . Date of fall: 02/17/2026 Time of of fall: 11:30 AM . Possible Cause: found down face down; picking up marshmallows and possibly choked on marshmallow . CNA was just by the door of the nurses station and this writer was just at nurses station when we heard a loud thump on the floor, upon checking in less than a minute [Resident #3] was facing down with blood all over on the floor and his color from his head to upper limbs was all purple. Write called the provider right away then checked on [Resident #3] again . oxygen and pulse and breathing, non detected initially. Provider checked for pulse apically [directly over the heart using a stethoscope], it took few minutes before it became detectable. Marshmallows are coming out from . mouth and nose, suctioning done. Unsure if choked then . fell or . was picking up marshmallows on the floor.A hospital Discharge summary, dated [DATE] at 3:01 p.m., stated, . admitted on [DATE] after a syncopal episode [passing out] and fall . Patient was eating marshmallows when . became pulseless, apneic [temporary cessation of breathing], and was noted to be cyanotic [purple discoloration of the skin, indicating lack of oxygen] for about 2 to 3 minutes. was then transferred to the emergency room. Patient was started on treatment for aspiration pneumonia . was requiring additional oxygen .A cardiology consult note, dated 02/19/26 at 2:05 p.m., stated, . Dx [diagnoses]: Troponin elevation-secondary to stress cardiomyopathy [a sudden, temporary weakening of the heart muscle triggered by intense emotional or physical stress] . [question mark] PEA [pulseless electrical activity] arrest [type of cardiac arrest where the heart the heart muscle is either not pumping or too weak to produce a detectable pulse] secondary to choking/hypoxia . Plan: Patient states . choked on the food and had difficulty breathing and apparently turned blue and passed out. Coronary CTA yesterday demonstrated nonobstructive CAD [coronary artery disease] pattern [no artery blockages].Review of the facility investigation report occurred 05/26/26. This report, completed after the incident on 02/17/26, stated, . [Resident #3's initials] had been eating . noon meal and CNA [CNA #4 initials] came to remove his tray when he finished. He was alert, oriented and wheeling around in his room. He had a bag of marshmallows on his over the bed table which he had been snacking on prior to lunch.During an interview on 05/26/26 at 4:10 p.m., two administrative nurses (#1 and #2) stated the marshmallows were not bite-sized. The CNA (#4) told them the resident's sister brought the marshmallows in the night before and Resident #3 snacked on them prior to lunch. During an interview on 05/26/26 at 4:30 p.m., an administrative nurse (#1) stated staff are not really educated on mechanically altered diets/IDDSI levels and what food items are allowed foods and not allowed.During an interview on 05/27/27 at 9:44 a.m., when asked how she would know what a resident can/can't have based on the ordered diet, the CNA (#4) stated, The nurse is in charge of that. Observation on 05/27/26 at 11:15 a.m. showed a CNA (#3) delivered a meal tray to Resident #3. The meal consisted of Salisbury steak (a whole patty), mashed potatoes, and baked apples cut in approximately 1 inch pieces topped with whipped cream. The CNA removed the cover, failed to cut the Salisbury steak patty, and exited the room. Resident #3 used a spoon to cut bites from the patty. During an interview on 05/27/26 at 11:34 a.m., a dietary supervisor (#6) stated kitchen staff do not cut food into bite-sized pieces prior to the meal leaving the kitchen. She confirmed Salisbury steak as soft. During interviews on 05/26/26 at 1:30 p.m. and 05/27/26 at 1:10 p.m., Resident #3 stated he fell because he passed out. When asked about his food restrictions, Resident #3 stated, Peas, steak, and nuts. When asked specifically about marshmallows, the resident stated, Marshmallows are a dirty word and The last time I took a bite of a marshmallow I passed out. During a telephone interview on 05/27/26 at 1:20 p.m., Resident #3's representative identified awareness of the resident's diet order for soft and bite sized food but the facility had not provided her with a list of restricted foods. She stated the facility informed her about the marshmallows brought in by the sister after the 02/17/26 incident. The representative verified the sister's current awareness of the marshmallow restriction.During a telephone interview on 05/27/26 at 2:31 p.m., a dietician (#7) confirmed she expected facility staff to cut the Salisbury steak into bite-sized pieces before delivery to residents with an order for soft and bite-sized food. During a telephone interview on 05/28/26 at 11:05 a.m., a speech language pathologist (#8) confirmed marshmallows are not appropriate for an ordered IDDSI level 6 soft and bite-sized diet, and she expected staff to cut meat patties into bite sized pieces for a resident with an order for IDDSI level 6 soft and bite-sized food. The facility failed to ensure the resident, resident representative, and staff understood appropriate food choices for Resident #3's ordered diet, and staff followed Resident #3's ordered diet.2. Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide adequate supervision and assistive devices for 1 of 4 sampled residents (Resident #3) observed during a transfer. Failure to use a gait belt and the appropriate number of staff during transfers placed all residents at risk for accidents, falls, or injuries.Findings include:Review of the facility policy titled Transferring Resident with Transfer (Gait) Belt occurred on 05/28/26. This policy, dated March 2025, stated, . It is the policy of this facility to use a gait/transfer belt to guide and support residents who: . May require assistance with a transfer due to the resident being unsteady and having the potential to fall . Place the transfer/gait belt around resident's waist . Refer to ADLs [activities of daily living] and use one or two staff members with transfer as careplanned [sic] for safety of resident and staff.Review of Resident #3's medical record occurred on all days of survey. Diagnoses included dizziness, weakness, syncope, and orthostatic hypotension (sudden drop in blood pressure when moving from lying/sitting to standing). The current care plan stated, . I have a Potential for Trauma-Falls . ADL door card is part of the care plan . provide assistance with ambulation, transfers, and assistive devices as per current ADL's . The ADL door card stated, . Transfers . recommend partial/moderate assist to pivot x2 [times two staff] with gait belt .Observation on 05/27/26 at 11:03 a.m. showed Resident #3 resting in bed. A certified nurse aide (CNA) (#3) entered the resident's room and assisted Resident #3 to stand and pivot to the wheelchair. The CNA failed to apply the gait belt and utilize a second staff member for the transfer.Observation on 05/28/26 at 9:35 a.m. showed Resident #3 seated in a shower chair with a gait belt around the waist. The resident held onto the assist bar on the wall and stood. A CNA (#5) placed the wheelchair behind the resident and the resident sat in the wheelchair. When asked if the CNA assisted the resident to transfer from the bed to the wheelchair alone prior to the bath, the CNA stated, Yes [Resident #3] is a one-person transfer.During an interview on 05/28/26 at 10:14 a.m. an administrative nurse (#1) confirmed Resident #3's care plan identified assist of two staff for transfers.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure proper labeling and storage of medications for 2 of 9 observations of medication preparation and administration. Failure to date an insulin pen with the open and discard date and failure to ensure medications are administered promptly after preparation may result in an ineffective dose of insulin and medication errors. Findings include:Review of the facility policy titled Medication Disposal occurred on 05/28/26. This undated policy stated, . Insulins are disposed of 28 days from the date opened unless otherwise specified by the manufacturer. These will be labeled with open and discard dates.Review of the facility policy titled Administration of Drugs occurred on 05/28/26. This undated policy stated, . Drugs are to be administered as soon as possible after doses are prepared. Medications should not be pre-dished for future medication passes.-Observation on 05/26/2026 at 5:05 p.m. showed a staff nurse (#9) prepared Resident #25's Humalog insulin pen for administration. The nurse obtained the pen from a plastic bag labeled with the resident's name. The pen lacked an open and discard date. -Observation on 05/26/26 at 5:25 p.m. showed three medication cups containing oral medication, labeled with resident first names, on top of the medication cart. A nurse (#9) prepared a fourth medication cup and labeled it with the resident's first name. When asked about pre-dishing the medications, the nurse (#9) stated she prepared the supper medications for a few residents so she could help feed residents in the dining room and would administer the medications to those four residents at that time. During an interview on 05/28/2026 at 10:59 a.m., an administrative nurse (#1) confirmed staff should label insulin pens with an open and discard date and confirmed staff should not pre-dish medications.

Based on survey findings, review of facility policy, professional reference, and staff interview, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to develop a Performance Improvement Project (PIP) to decrease or prevent the likelihood of problems or occurrences of adverse events, and ensure compliance with federal requirements related to a resident choking incident. Findings include:Review of the facility Quality Assurance and Performance Improvement Plan occurred on 05/28/26. The undated policy stated, . Scope . we provide comprehensive clinical care to residents . all care is resident-centered and focuses on choice and Individualized plans of care . Implementation . will be carried out by the Quality Assurance and Performance Improvement Plan Committee (QA), which . assures that the monitoring activities selected effectively cover all types of services and categories of care rendered . The facility conducts PIPs to examine and improve care and/or services in specifically identified areas. PIPs are chosen based on their importance and meaningfulness in relation to the scope of services provided by the facility.Review of the Complete IDDSI (International Dysphagia Diet Standardisation Framework accessed at iddsi.org, dated April 2026, stated, . describe texture modified foods . used for individuals with dysphagia [difficulty swallowing] . level 6 soft & [and] bite - sized . 'Bite-sized' pieces . Adults . 1.5 cm [centimeters] pieces (no larger than) . Food Textures That [NAME] A Choking Risk . Chewy textures are a choking risk because they are sticky and can become stuck on the roof of the mouth, the teeth or cheeks and fall into the airway. Examples of chewy textures: . marshmallows .Review of the facility investigation report completed after the incident on 02/17/26, stated . [Resident #3's initials] had been eating . noon meal and CNA [Certified Nurse Aide #4 initials] came to remove his tray when he finished. He was alert, oriented and wheeling around in his room. He had a bag of marshmallows on his over the bed table which he had been snacking on prior to lunch. they heard a loud crash coming from [Resident #3's initials] room. They responded immediately and found him prone on the floor next to his wheelchair . Suctioning was done due to excess secretions, and noted small white pieces of material that looked like marshmallow were removed. Review of Resident #3's current care plan stated, . I have a dx [diagnosis] of Dysphagia . I am at risk of aspiration [breathing food, liquid, saliva, or vomit into airway and lungs] and choking . Mechanically altered consistency . Level 6 soft and bite sized . During the survey team's investigation, interview on 05/26/26 at 4:10 p.m. two administrative nurses (#1 and #2). confirmed Resident #3 ate regular sized marshmallows (not miniature sized) on the day of the choking incident.After reviewing Resident #3's choking incident, the survey team consulted with the State Survey Agency (SSA) and it was determined an immediate jeopardy (IJ) situation existed on 02/17/26 at 11:30 a.m. The IJ resulted when staff failed to remove snack items not consistent with Resident #3's mechanically altered diet order from the resident's room which resulted in Resident #3 experiencing a choking episode and hospitalization.During an interview on 05/28/26 at 11:10 a.m., an administrative nurse (#2) stated in the past, QAPI monitored food temperatures, but not the accuracy of diets served to residents. During an interview on 05/28/26 at 11:48 a.m., a dietary supervisor (#6) confirmed the dietary QAPI process did not include diet accuracy.Refer to F689.

1. Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide adequate supervision for 2 of 3 sampled residents (Resident #38 and #204) with orders for electric heating pad use. Failure to provide adequate supervision during heating pad use resulted in a burn for Resident #38 and placed Resident #204 and all other residents who use heating pads at risk for burns. During the on-site recertification survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 02/07/24. The IJ was identified when a physician's order in Resident #38's medical record, dated 02/08/24, included a treatment for and a diagnosis of a first degree burn to the resident's right hip from an electric heating pad. This finding placed all residents who use an electric heating pad in immediate danger for burns. * 03/11/25 at 10:27 a.m., The survey team notified the administrator and the director of nursing (DON) of the IJ situation, provided the IJ template, and requested a plan for removal of the IJ. * 03/11/25 at 1:09 p.m., The survey team reviewed and accepted the facility's removal plan for the IJ. The removal plan contained the following: * Reviewed all resident medical records for electric heating pad use. Found eight residents with orders. Two of the eight residents had electric heating pads in their rooms which the staff removed. * Staff ensured all resident rooms free from electric heating pads. * All facility owned electric heating pads discarded. * Electric heating pad usage removed from all resident orders. * The updated electric heating pad policy stated, As of 03/11/25 Electric Heating Pads are no longer allowed for use in this facility. * The admission handbook updated to reflect the new policy. * The facility's medical provider notified about the new policy. * Residents, families, and staff notified via electronic and/or paper communication about the new electric heating pad policy. * 03/11/25 at 2:40 p.m., The survey team verified the implementation of the removal plan as of 03/11/25 and the IJ removal. The deficient practice remained at a G scope and severity following the removal of the IJ. Findings include: Review of the facility policy titled HEATING PAD occurred on 03/10/25. This policy, dated December 2024, stated, . Procedure . 3. Set the control to low and plug into . outlet. 4. After the pad warms up you may adjust the control to a warmer setting-watching closely that no increased redness or burns occur. 5. Begin timing the application. Remove heat pad after 15-20 minutes or as ordered. If resident is competent and wishes to use heating pad for more than 10-minute time limit . they must sign a 'Release from Responsibility' form. - Review of the facility's incident report related to Resident #38's burn, dated 02/07/24 at 11:45 p.m., stated, . Describe the Incident/Possible Causes: fragile skin, other: heating pad left on longer than 20 minutes (estimated 2.5 - 3 hours) CNA [certified nurse aide's name] called writer into room to show that heating pad was left on resident's right hip. Upon removal, a large reddened area was present. Heating pad setting was on medium. Usual application time is approximately 8:30 p.m. and heating pad was discovered in place at approximately 11:30 p.m. Time: 03:33 AM [3:33 a.m.] Writer assessed area once again and most of the redness dissipated but still has some blotches or reddened skin near top of pelvis . Review of Resident #38's medical record occurred on all days of survey. A provider visit note, dated 02/08/24, stated . [Resident #38] . requested to have her right hip evaluated, as she and nursing noted that she has a burn on her right hip. Nursing notes that [Resident #38] does have orders to use an electric heating pad, that can be in contact with her skin for up to 20 mins [minutes]. [Resident] notes that she thought the heating pad was turned up too high yesterday and 'fried' her. Nursing notes that the heating pad was left on the patient for about 5 hours. Review of Resident #38's physician's orders identified the following: * 11/01/23, Apply hydrocollator [a heating device which stores temperature controlled moist hot packs] or heating pad [electric] to right hip for 20 minutes daily at bedtime . * 02/08/24, Bacitracin [antibiotic topical ointment] TID [three times a day] to R [right] hip x [for] 7 days, cover w/ [with] Telfa [a non-stick wound dressing] after application. Dx [diagnosis]: 1st degree burn [a mild burn injury of the outermost layer of the skin] R hip. D/C [discontinue] order for heating pad, only use hot packs for up to 20 minutes at a time. * 02/12/24, Bacitracin & [and] telfa to blisters R hip Bid [twice a day] until healed. Review of Resident #38's nursing progress notes, dated February 8-20, 2024, showed the following: * 02/08/24 at 6:22 a.m., . Right hip burn is already starting to form blisters and has one site that is peeling, skin periphery [outer edge] is reddened. * 02/08/24 at 2:30 p.m., . has two blisters but not puffy. * 02/08/24 at 10:00 p.m., . on right hip, redness surrounding blistered area, approximately 2 [cm] [centimeters] x [by] 5 cm. * 02/09/24 at 1:52 p.m., . Burns are blistered and fluid filled. Slightly reddened periphery. * 02/20/24 at 10:23 p.m., . right hip blister, dry healed; will d/c treatment. The facility failed to monitor Resident #38's use of the heating pad which resulted in a burn. - Review of Resident #204's medical record occurred on all days of survey. A physician's order, dated 03/05/25, stated, . Heating pad to areas of pain/discomfort x [for] 15-20 minutes as needed. May keep at bedside to use at own discretion . Observation on 03/10/25 at 5:02 p.m. showed Resident #204 in her room with a heating pad on the high temperature setting located on her upper legs and knees. The resident stated she brought the heating pad from her home and confirmed the pad does not have an automatic shut off. During interviews on 03/10/25 at 4:28 p.m. and at 5:33 p.m., an administrative nurse (#1) stated heating pad means electric heating pads, and some residents use heating pads at their own discretion. The administrative nurse (#1) also stated CNAs apply/remove heating pads and monitor the length of time the pad is in place and a nurse confirms the CNA completed the treatment and documents the treatment completion in the Resident's treatment administration record (TAR). The administrative nurse (#1) confirmed Resident #38's TAR failed to show a start and stop time for the heating pad use and Resident #204's TAR lacked documentation of electric heating pad use. 2. Based on observation, record review, review of facility policy, and staff interview, the facility failed to properly utilize assistive devices necessary to prevent accidents and/or injury for 2 of 3 sampled residents (Resident #21 and #41) observed during transfers. Failure to provide transfer assistance, utilize gait belts, and lock wheelchairs placed the residents at risk for falls and/or injury. Findings include: Review of the facility policy titled Transferring Resident with Transfer (gait) Belt occurred on 03/12/25. This policy, dated December 2024, stated, . It is the policy of this facility to use a gait/transfer belt to guide and support residents who: require assistance with transfer . - Review of Resident #21's medical record occurred on all days of survey. Diagnoses included weakness, ataxic gait (poor muscle control), difficulty walking, unsteadiness on feet, and dementia. A quarterly Minimum Data Set (MDS), dated [DATE], identified the resident required substantial/maximal assistance with bed to chair transfers. The care plan stated, I have alteration in . mobility . hx [history] of falls . gait problems . unsteadiness on my feet . Observation on 03/11/25 at 11:23 a.m., showed two CNAs (#3 and #4) entered Resident #21's room. Without staff assistance, the resident sat up in his bed, and in a hunched over position and an unsteady shuffled gait, placed himself into a wheelchair. The right brake of the wheelchair was not locked and the wheelchair moved backwards. Both CNAs (#3 and #4) failed to provide Resident #21 transfer assistance and failed to ensure both wheelchair brakes were locked. - Review of Resident #41's medical record occurred on all days of survey. Diagnoses included hemiplegia (paralysis to one side of the body), muscle weakness, dizziness, and repeated falls. A quarterly MDS, dated [DATE], identified substantial/maximal assistance required with transfers on and off the toilet. The CNA care card identified, . medical staff recommends pivot [transfer] assist of one [staff] with gait belt . Observation on of 3/11/25 at 11:00 a.m. showed a CNA (#3) positioned Resident #41's wheelchair in front of the toilet. The resident used a grab bar to pull herself to a partial standing position, and with an unsteady gait, hopped on her right toes towards the toilet. The residents left foot drug along the floor, and she stumbled during the transfer. The CNA (#3) failed to utilize a gait belt and provide Resident #41 transfer assistance. During an interview on 03/13/25 at 12:20 p.m., an administrative nurse (#1) confirmed she expected staff to utilize a gait belt during Resident #21 and #41's transfers and expected staff to notify nursing of difficult transfers. 3. Based on observation, review of Safety Data Sheets (SDS), and staff interview, the facility failed to ensure an environment free of accident hazards in 1 of 3 open kitchen areas (200 wing). Failure to store chemicals in locked cupboards placed residents in this household at risk for injury. Findings include: Review of an untitled and undated facility policy occurred on 03/13/25. This policy stated, . Housekeepers must keep a constant [NAME] out for chemicals that are within a resident's reach. If it says on the chemical product to keep out of reach of children the product MUST be stored . in the CNA storage room. Observation on the morning of 03/13/25 identified chemicals in unlocked cupboards in an open kitchen area in the 200 wing. Residents frequented the area and could access the cupboards. The cupboards contained the following: * Underneath the sink, an uncovered can of Lysol Disinfectant Aerosol Spray. * Above the right side of the sink, three covered cans of Airworks Aerosol Air Freshener. * Above the microwave, two covered cans of Airworks Aerosol Air Freshener, one container of Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant Wipes, and one container of Clorox Healthcare Bleach Germicidal Wipes. Review of the SDS for the chemicals identified the following: * Lysol Disinfectant Aerosol Spray, . CAUTION Causes moderate eye irritation. Do not spray in eyes, on skin or on clothing. KEEP OUT OF REACH OF CHILDREN . * Airworks Aerosol Air Freshener, . Eye Contact: Causes eye irritation. Skin Contact: May cause irritation. Ingestion: Pain, nausea, vomiting and diarrhea. Inhalation: May cause nasal discomfort and coughing. * Clorox Healthcare Bleach Germicidal Wipes, . KEEP OUT OF REACH OF CHILDREN . CAUTION: liquid causes moderate eye irritation. Do not get into eyes or on clothing. Wash thoroughly with soap and water after handling . * Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant Wipes, . KEEP OUT OF REACH OF CHILDREN . CAUTION: Causes moderate eye irritation. Avoid contact with eyes or clothing. Wash thoroughly with soap and water after handling . During an interview on 03/13/25 at 8:46 a.m., a staff member (#8) stated residents utilize the open kitchen area on Wing 200 as a space outside of their rooms to relax and read. During an interview on 03/13/25 at 8:52 a.m., an administrative nurse (#1) stated she expected staff to store aerosol sprays and disinfectant wipes in locked cupboards/areas. 46477 40489

Based on review of the Electronic Staffing Data Submission Payroll-Based Journal (PBJ) Long-Term Care Facility Policy Manual and staff interview the facility failed to submit direct care staffing information based on payroll data to the Electronic Staffing Data Submission PBJ for 1 of 4 reporting periods (Quarter #4). Failure to submit direct care staffing information may result in inaccurate representation of the level of staff in the facility which can impact the quality of care delivered. Findings include: The June 2022, version 2.6 Electronic Staffing Data Submission Payroll-Based Journal (PBJ), pages 1-3, stated, . Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate . Facilities that do not meet these requirements will be considered noncompliant and subject to enforcement actions by CMS [Centers for Medicare and Medicaid Services] . Review of the PBJ Data Staff Report CASPER Report (a CMS report) 1705D FY (fiscal year) Quarter 4 (July 1 - September 30, 2024) occurred on 03/12/25, and stated, . Failed to Submit Data for the Quarter . Triggered . During a phone interview on 03/12/25 at 11:08 a.m., an office staff member (#7) confirmed the facility failed to submit staffing data for the reporting period listed on the report.

Based on record review, review of facility policy, review of the facility investigation report, and staff interview, the facility failed to report an incident of potential neglect to the State Survey Agency (SSA) for 1 of 1 sampled resident (Resident #38) who experienced a burn from an electric heating pad. Failure to report an event of potential neglect to the SSA in the required time frame placed Resident #38 and other residents at risk for burns. Findings include: Review of the facility titled ABUSE PROHIBITION PLAN occurred on 03/11/25. This policy, dated December 2024, stated, The resident has the right to be free from . neglect . Neglect includes the failure of the facility, its employees, or service providers to provide goods or carry out resident services as directed or ordered by the physician or other authorized personnel necessary to avoid physical harm, pain, mental anguish or emotional distress. Failure to give proper attention to residents, or failure to carry out resident services through indifference, disregard for patient care, or careless oversight are examples of neglect. An alleged violation is a situation or occurrence that is observed or reported by staff . but has not yet been investigated. Alleged violations must be recorded and reported to the Administrator and/or Director of Nursing immediately. Immediate reporting will be faxed or sent via email to the State Health Department . Immediate means as soon as possible, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. If the events that cause the allegation does not involve abuse and does not result in serious bodily injury, it must be reported not to exceed 24 hours after discovery of the incident. The Administrator or the Director of Nursing shall report the result of all investigations to the State Survey and Certification Agency within 5 working days of the incident. Review of Resident #38's medical record occurred on all days of survey. Physician's orders identified the following: * 11/01/23, Apply hydrocollator [a heating device which stores temperature controlled moist hot packs] or heating pad [electric] to right hip for 20 minutes daily at bedtime . * 02/08/24, Bacitracin [anitbiotic topical ointment] TID [three times a day] to R [right] hip x [for] 7 days, cover w/ [with] Telfa [a non-stick wound dressing] after application. Dx [diagnosis]: 1st degree burn [a mild burn injury of the outermost layer of the skin] R hip. D/C [discontinue] order for heating pad, only use hot packs for up to 20 minutes at a time. Review of the facility's incident report, dated 02/07/24 at 11:45 p.m., stated, . Describe the Incident/Possible Causes: fragile skin, other: heating pad left on longer than 20 minutes (estimated 2.5 - 3 hours) CNA [certified nurse aide's name] called writer into room to show that heating pad was left on resident's right hip. Upon removal, a large reddened area was present. Heating pad setting was on medium. Usual application time is approximately 8:30 p.m. and heating pad was discovered in place at approximately 11:30 p.m. Time: 03:33 AM [3:33 a.m.] Writer assessed area once again and most of the redness dissipated but still has some blotches or reddened skin near top of pelvis . A nursing progress note, dated 02/08/24 at 6:22 a.m., stated, Right hip burn is already starting to form blisters and has one site that is peeling, skin periphery is reddened. Resident #38's medical record lacked evidence the facility reported the burn to the SSA as possible abuse/neglect. During an interview on 03/10/24 at 4:28 p.m., an administrative nurse (#1) confirmed the facility failed to report Resident #38's burn to the SSA

Based on record review, review of facility policy, and staff interview, the facility failed to ensure the resident or their representative chose to accept or decline a bed hold for 2 of 3 sampled residents (Resident #38 and #46) reviewed for hospitalizations. Failure to obtain a resident or their representative's bed hold choice does not allow the resident and/or their representative to make an informed decision regarding their rights. Findings include: Review of the facility policy titled Bed Hold occurred on 03/13/25. This policy, dated December 2024, stated, Notices of the . Bed Hold/Release notice will be given at each hospitalization . The resident or responsible party is to choose which they would like either to hold or release the bed . - Review of Resident #38's medical record occurred on all days of survey and identified a hospitalization on 01/29/25. The record failed to identify if the resident and/or their representative accepted or declined a bed hold. An office staff member (#6) provided an undated and unsigned bed hold form for the hospital stay. The office staff member (#6) stated she emailed a copy of the bed hold form to Resident #38's representative on 01/30/25, had not heard back from the representative, and failed to contact the representative after sending the email. - Review of Resident #46''s medical record occurred on all days of survey and identified a hospitalization on 01/11/25. The record failed to identify if the resident or their representative accepted or declined a bed hold. A progress note, dated 01/12/25 at 6:58 a.m., stated, . Bed hold/release form sent to [resident's power of attorney name]. The office staff member (#6) stated she emailed a copy of the bed hold form to Resident #38's representative on 01/12/25, had not heard back from the representative, and failed to contact the representative after sending the email. During an interview on 03/12/25 at 2:44 p.m., the office staff member (#6) confirmed the facility failed to contact Resident #38 and #46's representatives to accept or decline a bed hold during their hospital stays.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 12 sampled residents (Resident #30). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2024, page A-32, stated, . Complete if A0310A = 01 . Annual assessment . Coding Instructions Code A, Serious mental illness: if resident has been diagnosed with a serious mental illness . Review of Resident #30's medical record occurred on all days of survey. The medical record included the diagnosis of paranoid schizophrenia. The facility failed to code the serious mental illness on the annual MDS, dated [DATE]. During an interview on 03/13/25 at 12:10 p.m., administrative staff members (#1 and #5) confirmed staff failed to code Resident #30's MDS for a serious mental health illness.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 3 of 12 sampled residents (Resident #21, #22, and #38). Failure to update care plans limited the staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Nursing Care Plans occurred on 03/12/25. This policy, dated December 2024, stated, A nursing care plan directs the resident's nursing care . The Care plan should be written individually for each resident, making it resident-centered. Planning is to be continuous (on-going) . Review of the facility policy titled Trauma Informed Care occurred on 3/12/25. This policy, dated December 2024, stated, . The facility will collaborate with resident trauma survivors . to develop and implement individualized care plan interventions. Trigger specific interventions will identify ways to mitigate or decrease the effect of the trigger . and will be added to the resident's care plan. - Review of Resident #21's medical record occurred on all days of survey. Diagnoses included post-traumatic stress disorder (PTSD). The facility failed to update Resident #21's care plan to reflect triggers and interventions related to history of PTSD. - Review of Resident #22's medical record occurred on all days of survey. Diagnoses included PTSD. The facility failed to update Resident #22's care plan to reflect triggers and interventions related to history of PTSD. During an interview on 03/13/25 at 12:19 p.m., an administrative nurse (#1) confirmed the facility failed to update Resident #21 and #22's care plans to reflect triggers and interventions for PTSD. - Review of Resident #38's medical records occurred on all days of survey. The record identified a physician's order for oxygen use. Observations on all days of survey showed the resident wore oxygen per nasal cannula. Resident #38's care plan lacked a problem, goal, and interventions related to oxygen use. During an interview on 03/12/25 at 11:55 a.m., an administrative nurse (#2) confirmed Resident #38's care plan lacked a specific problem for oxygen use.

Based on observation, review of facility policy, and staff interview, the facility failed to prepare, store, and serve food in a sanitary manner in 1 of 1 kitchen. Failure to discard outdated food items and monitor the sanitizer concentration may result in unsafe food storage/preparation and foodborne illness. Findings include: OUTDATED FOOD ITEMS Review of the facility policy titled Food Safety Requirements occurred on 01/25/24. This policy, revised January 2024, stated, . Practices to maintain safe refrigerated storage include . Labeling, dating, and monitoring refrigerated food . so it is used by its use-by date, or . discarded . Observation of the kitchen on 01/22/24 at 11:00 a.m. and 01/24/24 at 11:18 a.m. showed six quart-sized cartons of buttermilk sitting on a shelf in the walk-in refrigerator. Each carton was dated 01/06/24 (19 days past the use-by date). A managerial dietary staff member (#3) confirmed she would discard the outdated buttermilk. SANITIZER Review of the facility policy titled Sanitation Inspection occurred on 01/25/24. This policy, revised January 2024, stated, . The department shall establish a sanitation program for food services . The dietary manager shall develop and provide food service personnel with standard operating procedures for sanitation . Observation on 01/22/24 at 11:00 a.m. showed a bucket filled with a sanitizer solution in the food preparation area of the kitchen. A managerial dietary staff member (#3) indicated the sanitizer solution contained chlorine and asked a staff member to retrieve test strips from the other room. The dietary staff member (#5) returned with test strips, tested the solution, and obtained a reading of 170 ppm (parts-per-million), which is outside the acceptable 50-100 ppm range for a chlorine solution. During an interview on 01/23/24 at 3:15 p.m., the managerial dietary staff member (#3) stated, I think we used the wrong test strips yesterday. I think we used [brand name] test strips. I'm not sure what the chemical is. [Name of corporation] brings it. When asked how staff typically mix the sanitizer solution, the dietary staff member (#5) stated, I usually do a quarter cup, like two ounces, like two lids full. When asked if they monitor the concentration of the solution, the managerial dietary staff member (#3) stated, No, we don't have a log for this.

Based on observation, review of the North Dakota Plumbing Code, and staff interview, the facility failed to provide an air gap for 1 of 1 two-compartment sink observed in the main kitchen. Failure to provide the required air gap for a two-compartment sink has the potential to allow contamination of the sink in the event of a sewer back up. Findings include: Review of the 2018 North Dakota Plumbing Code, Section 801.2 Air Gap or Air Break Required, stated, Indirect waste piping shall discharge into the building drainage system through an air gap or air break as set forth in this code. Where a drainage air gap is required by this code, the minimum vertical distance as measured from the lowest point of the indirect waste pipe or the fixture outlet to the flood-level rim of the receptor shall be not less than 1 inch (25.4 mm). Section 801.3.3 Food-Handling Fixtures, stated, Food-preparation sinks, steam kettles, potato peelers, ice cream dipper wells, and similar equipment shall be indirectly connected to the drainage system by means of an air gap. Bins, sinks, and other equipment having drainage connections and used for the storage of unpackaged ice used for human ingestion or used in direct contact with ready-to-eat food, shall be indirectly connected to the drainage system by means of an air gap. Each indirect waste pipe from food-handling fixtures or equipment shall be separately piped to the indirect waste receptor and shall not combine with other indirect waste pipes. The piping from the equipment to the receptor shall be not less than the drain on the unit and in no case less than 1/2 of an inch (15 mm). Observations on 01/23/24 at 3:15 p.m. and 01/24/24 at 11:18 a.m. showed the end of a two-compartment sink drainpipe ending approximately three inches below the rim of a cut out in the tiled flooring that contained the grease trap/floor drain. During an interview on 01/24/24 at 2:15 p.m., a maintenance staff member (#1) confirmed the two-compartment sink failed to have an air gap.

Based on record review and staff interview, the facility failed to provide the resident or the resident's representative a written notice of transfer for 1of 1 resident (Resident #22) reviewed for hospital transfer. Failure to provide a written copy of the transfer notice does not allow the resident and/or their representative to make an informed decision regarding their rights. Findings include: Review of Resident #22's medical record occurred on all days of survey. A hospital transfer occurred on 12/21/23. The medical record lacked documentation the facility provided the resident and/or representative with a written transfer notice. During an interview on 01/24/24 at 4:45 p.m., an administrative staff member (#2) confirmed the facility failed to provide written notice of a transfer to the family/representative.

Based on record review, review of facility policy, and staff interview, the facility failed to provide the resident or resident's representative a written bed hold notice for 1 of 1 resident (Resident #22) reviewed for hospital transfer. Failure to provide a written copy of the bed hold notice and include the reserve bed amount does not allow the resident and/or their representative to make an informed decision regarding their rights. Findings include: Review of the facility policy Bed Hold occurred on 01/25/24. This undated policy, stated, Before a resident is transferred to a hospital or goes on therapeutic leave, the facility will provide written information to the resident and a family member or legal representative that specifies the duration of the bed-hold policy. The resident, or a person acting on behalf of the resident, must request that the bed be held and informed of the charges. Review of Resident #22's medical record occurred on all days of survey. A hospital transfer occurred on 12/21/23. The medical record lacked documentation the facility provided the resident and/or their representative with a written bed hold notice or the reserve bed hold amount. During an interview on 01/24/24 at 4:45 p.m., an administrative staff member (#2) confirmed the facility failed to provide a written bed hold notice or the reserve bed hold amount to the family/representative.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 7 residents (Resident #4 and #31) prescribed Aspirin. Failure to accurately complete the MDS for medications taken by the residents may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI User's Manual, dated October 2023, pages N-1, and N-6 to N-8 stated, Section N Medications . N0415: High-Risk Drug Classes . Coding Instructions: Code all high-risk medications according to their pharmacological classification, not how they are being used. N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g., [for example] aspirin/extended release . ) was taken by the resident at any time during the 7-day observation period . - Review of Resident #4's medical record occurred on all days of survey. A physician's order, dated 12/19/23, stated, Aspirin 325mg [milligram] EC [Enteric Coated] by mouth daily [antiplatelet medication] . The admission MDS, dated [DATE], showed staff failed to code Resident #4's use of an antiplatelet medication. - Review of Resident #31's medical record occurred on all days of survey. A physician's original order, dated 2/19/23, state, Aspirin 325mg EC tab 1 tab by mouth daily . The quarterly MDS, dated [DATE], showed staff failed to code Resident #31's use of an antiplatelet medication. During an interview on 01/23/24 at 11:38 a.m., an administrative nurse (#4) identified the aspirin should have been coded as an antiplatelet medication.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure posting of accurate and complete staffing information on 3 of 4 days of survey (January 22-24, 2024). Failure to post accurate staffing data does not allow residents and visitors to be aware of the number of licensed and unlicensed staff on duty each shift. Findings include: Review of the facility's Posting of Staff policy occurred on 01/25/24. This undated policy stated, . The charge nurse will be responsible to do the staffing report daily. The nurse with C by her name will fill out the form for the next shift . Observation of the daily staffing report occurred on January 22-24, 2024. The report failed to identify all categories of licensed and unlicensed nursing staff directly responsible for resident care per shift on the three days observed. During an interview on 01/25/24 at 10:25 a.m., an administrative nurse (#2) agreed the posting of staff should have been updated at the beginning of every shift. The facility failed to ensure the posted staffing information was accurate and complete.

Based on observations, review of facility policies, and staff interviews, the facility failed to label and date food, and discard food beyond the use by date in 2 of 5 resident refrigerators (Residents #6 and #27) and 2 of 2 facility snack/nourishment refrigerator (100 wing and central nurses station). Failure to label and date food items and discard food beyond the use by date may result in the spread of foodborne illness to residents, staff, and visitors. Findings include: Review of the facility policy titled Resident Refrigerators occurred on 03/28/23. This policy, dated March 2011, stated . food is to be checked for spoilage. Review of the facility policy titled Use and Storage of Food Brought in by Family or Visitors occurred on 03/28/23. This policy, revised January 2023, stated . food items . must be labeled with content and dated. the facility may refrigerate labeled and dated prepared items . If not consumed within 3 days, food will be thrown away by facility staff. An observation of Resident #6's refrigerator, on 03/27/23 at 9:45 a.m., identified the following: * Labeled ham with a use by date of 03/19/23. (eight days past the use by date) * Labeled fleischkuekle (deep fried dumpling with seasoned ground beef) with a use by date of 03/18/23. (nine days past the use by date) An observation of Resident #27's refrigerator, on 03/27/23 at 10:17 a.m., identified a unlabeled and undated medium size plastic container containing unidentifiable food. An observation of the facility's snack/nourishment refrigerator/freezer (100 wing), on 03/27/23 at 11:18 a.m., identified the following: * Unlabeled and undated piece of cream type pie. * Three unlabeled and undated small plastic containers containing unidentifiable food. An observation of the facility's snack/nourishment refrigerator (by the central nurse's station), on 03/27/23 at 11:27 a.m., identified the following: * Labeled cheese with a use by date of 03/15/23. (12 days past the use by date) * Labeled white bread with use by date of 03/25/23. (two days past the use by date) * Labeled luncheon meat with use by date of 03/25/23. (two days past the use by date) During a interview on 03/27/23 at 9:45 a.m., a CNA (certified nursing assistant) (#2) stated the housekeeping staff, CNAs, and nurses are responsible for maintaining resident refrigerators and the snack/nourishment refrigerator/freezer (100 Wing). During a interview on 03/29/23 at 10:07 a.m., an administrative staff member (#1) stated that kitchen staff are responsible for monitoring and cleaning of the snack/nourishment refrigerator (by the central nurse's station).

Based on observation, record review, and resident and staff interview, the facility failed to provide reasonable accommadations for 1 of 1 sampled resident (Resident #24) who requested a bed positioning device. Failure to apply Resident #24's repositioning device in a timely manner may result in pain and place the resident at risk for falls. Findings include: Review of Resident #24's medical record occurred on all days of survey. Diagnoses included ankle fracture. The current care plan, dated 03/21/23, stated, . at risk for falls due to: History of falls . maintain safe environment and free of falls related to injury . wear boot at all times on ankle except when resting in bed . elevate . reposition ankle as needed . administer pain medication . Observation on 03/27/23 at 10:58 a.m. showed Resident #24 lying in bed with the right leg elevated on two pillows and the foot touching the foot board on the bed. The resident complained of right leg and back pain while trying to move his foot away from the foot board. During an interview on 03/27/23 at 10:58 a.m., Resident #24 stated he requested staff apply the bed trapeze from the other bed in his room to his bed or to switch beds on 03/09/23. The resident stated he requires staff assistance to position his right leg and the trapeze would aid in his mobility. Observation on the afternoon of 03/27/23, showed staff installed a bed trapeze on Resident #24's bed. Review of the resident's progress notes, dated 03/28/23 at 01:57 p.m., stated . a late entry for 03/09/23: Resident requesting a trapeze over his bed as had used one in the hospital and wanted it for repositioning . Physical Therapy placed a note in the maintenance book to have one placed . Staff installed the bed trapeze 18 days after the resident request. During a interview on 03/28/23 at 2:01 p.m., an administrative nurse (#4) stated she expected staff to install Resident #24's positioning equipment timely. During a interview on 03/29/23 at 11:07 a.m., an administrative nurse (#3) stated the facility failed to make reasonable accommodations for Resident #24's mobility equipment and update the care plan and care card.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure a system to account for controlled medications in order to enable an accurate reconciliation of medications for 1 of 2 observations (01/11/22 at 11:00 a.m.) of medication pass. Failure to ensure staff account and perform periodic reconciliation of [MEDICATION(S)] (a controlled medication used for pain) may cause medication loss or diversion of medications. Findings include: Review of the facility policy titled Marion Manor Pharmaceutical Services Policy occurred on 01/12/22. This undated policy, stated, . Record of receipt and disposition of all controlled drugs will be maintained in sufficient detail to enable accurate reconciliation. Observation of medication pass on 01/11/22 at 11:00 showed a licensed nurse (#11) administered [MEDICATION(S)] and failed to reconcile the medication. During an observation of the medication cart on 01/12/22 at 1:15 p.m. a licensed nurse (#10) stated the facility does not reconcile [MEDICATION(S)]. During an interview on 01/12/22 at 2:08 p.m. an administrative nurse (#1) confirmed [MEDICATION(S)] is a controlled medication and the facility failed to reconcile the medication. This administrative nurse followed up with the consultation pharmacist who confirmed [MEDICATION(S)] needed to be reconciled.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 02/06/20 Based on observation, review of facility policy, and staff interview, the facility failed to ensure staff followed proper infection control practices for 3 of 8 sampled residents (Resident #35, #38 and #40) observed during incontinence cares. Failure to follow proper infection control practices for hand hygiene has the potential to transmit infectious agents to residents, staff and visitors. Findings include: Review of the facility policy titled Hand Hygiene occurred on 01/12/22. This policy, revised, June 2021, stated, . All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to . When, during resident care, moving from a contaminated body site to a clean body site . After assistance with personal body functions (e.g., elimination, .) . 4. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. - Observation on 01/10/21 at 3:33 p.m. showed two certified nurse aides (CNAs) (#3 and #4) transfer Resident #38 from the wheelchair to the toilet using a mechanical sit to stand lift. The CNA (#3) donned gloves and removed Resident #38's soiled brief. After lowering the resident onto the toilet, the CNA (#3) removed her gloves and without performing hand hygiene opened the bedside drawer, retrieved a new brief, and left the room to retrieve more gloves. Upon returning to the room the CNA (#3) did not perform hand hygiene. The CNA donned new gloves, performed incontinence cares, removed her gloves and without performing hand hygiene assisted CNA (#4) to adjust the resident's brief and pants, and assisted the resident to the bed with the mechanical sit to stand lift. The CNA (#3) failed to perform hand hygiene before and after incontinence cares and glove removal. - Observation on 01/11/22 at 9:54 a.m. showed two CNAs (#8 and #9) provided incontinence care for Resident #35. The CNA (#8) cleansed the perineal area of liquid stool, removed her gloves and without performing hand hygiene opened the closet and nightstand drawers looking for more perineal wipes. The CNA (#8) used the two way radio to request more wipes. An unidentified staff member provided more wipes and the CNA (#8) completed the perineal care, removed her gloves and performed hand hygiene. - Observation on 01/10/22 at 3:21 p.m., showed Resident #40 resting in bed. CNAs (#3 and #4) donned gloves. The CNA (#3) removed the soiled brief, performed incontinence care, placed a new brief, removed gloves and without performing hand hygiene, donned new gloves. The CNA (#3) assisted with putting Resident #40's pants on and placed a mechanical lift sling under the resident. The CNA (#3) removed her gloves and assisted transferring Resident #40 into the wheelchair and touched several items before performing hand hygiene Observation on 01/11/22 at 8:27 a.m., showed two CNAs (#5 and #6) enter Resident #40's room and perform a check and change. The CNA (#6) performed incontinence care, removed soiled gloves, performed hand hygiene, placed a clean brief, and upon turning the resident found a soiled wipe. The CNA (#6) removed the soiled wipe with a bare hand, and without performing hand hygiene continued cares. The CNA touched multiple items before performing hand hygiene upon exiting the room. During an interview on 01/12/22 at 11:15 a.m., two administrative nurses (#1 and #2) stated they expected staff to perform hand hygiene after removing gloves or touching contaminated items and per policy.

Based on review of Medicare Part A letters/notices and staff interview, the facility failed to ensure the completion of the Centers for Medicare/Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) form (CMS- ) for 2 of 2 sampled residents (Resident #17 and #40) discharged from Medicare Part A services who remained in the facility. Failure to ensure the residents received all available options for care and to appeal the termination of coverage has the potential to hinder the residents' right to an expedited review of a service termination. Findings include: Review of the Medicare Part A letters/notices for Residents #17 and #40 occurred the morning of 01/11/22. The review identified the facility sent the SNFABN forms to Resident #17 on 11/08/21 and to Resident #40 on 09/30/21. The residents/representative failed to return the SNFABN forms to the facility, and the facility failed to obtain communication/documentation of the resident's wishes for continued services and/or the option to appeal the termination of Medicare Part A coverage. During an interview on 01/11/22 at 11:20 a.m., an administrative staff member (#7) confirmed staff failed to obtain the SNFABN forms from Resident #17 and Resident #40.