Magnolia Manor Methodist Nsg C

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]