Magnolia Wellness Center

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate treatment and services for two residents with pressure ulcers (wounds related to prolonged pressure on bony prominences) (Resident #1 and #5) and interventions to prevent pressure ulcers for one resident (Resident #1). The facility failed to provide treatments as ordered and change dressings when saturated, (Residents #1 and #5). The facility also failed to provide Residents #1 with a low air loss mattress (LAL, special mattress that reduces pressure and moisture to prevent wounds) set to the correct settings and pressure-reducing devices, per the care plan. Staff did not lay Resident #5 in bed between meals, as recommended by the Wound Physician and Director of Nursing. Resident #1 and Resident #5 both experienced worsening pressure ulcers. The sample size was 21. The census was 74. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident safety and protective oversight. During a staff-assisted transfer from a wheelchair to a bed, one resident's (Resident #16) foot became entangled in the wheelchair wheel, resulting in a femur fracture requiring hospitalization and surgical repair. In addition, the facility failed to follow its mechanical lift policy during a resident transfer (Resident #69) and failed to ensure safe smoking practices for residents who smoked (Residents #32, #66 and #71) and follow the smoking policy and schedule. The sample size was 21. The census was 74. Review of the gait belt policy, revised 6/2020, showed:-Purpose: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment by not providing an adequate supply of linens for resident care. In addition, the first-floor dining room had areas with baseboards missing, creating holes in the wall. The census was 74. Review of the facility's Residents Rights policy last revised August 2020, showed, the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life. 1. Observation on 6/8/26 at 5:30 A.M., of the second-floor linen room showed two blankets and no other linen. The linen cart had one fitted bed sheet and two towels. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (Resident #12) received adequate supervision and interventions to ensure his/her safety while on Leave of Absence (LOA). Resident #12 admitted to consuming alcohol while on LOA and returned to the facility twice, with injuries from reported altercations while on LOA. The facility did not develop interventions and revise the resident's care plan regarding the frequent LOAs, the medications that were not received while on LOA, and the safety concerns for the resident while he/she was on LOA. The sample was 11. The census was 76. Review of the facility's Out on Pass policy, revised August 2020, showed:-It was the policy of the facility to meet resident's physical and psychosocial needs to go out on pass. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary behavioral health care services for four residents' psychosocial well-being when staff did not address the resident's behaviors, which included repeatedly violating the Drug and Alcohol Abuse, Out on Pass, Visiting and Contraband policies and demonstrating physical and verbal aggression toward other residents and staff (Residents #4, #1, #7 and #5). The sample was 11. The census was 80. Review of the facility's behavior management policy, revised June 2020, showed:-Purpose: To implement the most desirable and effective interventions to change, modify, decrease, or eliminate behaviors that are distressing to the resident, and/or are decreasing or negatively impacting the residents' quality of life. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. Staff failed to accurately and thoroughly document the controlled substance shift change inventory tracker sheets, for one of the two facility floors. The census was 80. Review of the facility's Controlled Substance Prescriptions policy, revised August 2020, showed the following:-Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow the abuse prevention policy and complete a thorough investigation related to an injury of unknown origin for one resident (Resident #16), when the facility identified healed right rib fractures from an unknown cause. The census was 76. Review of the Abuse Prevention and Prohibition Program, revised October 24, 2022, showed:-Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff provided adequate assistance to prevent accidents for one of four sampled residents (Resident #1) when Certified Nursing Assistant (CNA) B and CNA C used a Hoyer lift (full body lift, used for residents who are unable to move themselves), to transfer the resident but did not use the correct size sling. While the resident was suspended in mid-air, the sling straps broke, and the resident fell to the ground and hit his/her head. This caused a laceration (cut) to the posterior side (back side) of the resident's head. The resident was sent to the hospital and required sutures. The sample size was 4. The census was 92. The facility was notified of the past non-compliance on 10/24/25. The facility initiated their investigation and suspended both CNAs pending investigation. All staff were in-serviced. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two residents' right to be free from abuse was not violated, when a staff member threatened a resident, using profanity and was held back by other staff (Resident #6). In addition, Residents #1 and #2 were involved in a physical resident to resident altercation. Resident #2 flipped Resident #1's mattress over, which caused Resident #1 to fall and hit the floor. The sample was 9. The census was 85. The Administrator was notified on 8/15/25 at 9:56 A.M. of the past non-compliance, which began on 7/13/25. The facility immediately separated Resident #6 and the employee, who threatened the resident. The employee was suspended pending investigation and later terminated. Staff determined there was no physical injury to the resident. The resident's care plan was updated and social services followed up with the resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were treated with respect and dignity when an employee did not accommodate one resident's request for condiments during meal service, and engaged in an argument with the resident (Resident #3). The sample was seven. The census was 86. The Administrator was notified on 6/25/25 at 3:53 P.M., of the past non-compliance, which occurred on 6/15/25. The facility provided in-servicing for staff regarding interventions to deescalate when a resident becomes agitated. The deficiency was corrected on 6/23/25. Review of the facility's Privacy and Dignity policy, revised June 2020, showed: -Purpose: To ensure that care and services provide by the facility promote and/or enhance privacy, dignity and overall quality of life; -Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 34 opportunities observed, nine errors occurred resulting in a 26.47% error rate (Residents #11, #7, #12 and #4). In addition, Resident #1, Resident #4, and residents attending the 3/3/25 Resident Council meeting complained about receiving medications late. The census was 86. Review of the facility Medication-Administration policy, dated 5/2017, showed: -Policy: It is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations; -Procedure: -Medications are prepared, administered, and recorded only by licensed nursing, Certified Medications Technicians (CMTs), medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who required enhanced barrier precautions (EBP) for infection control interventions had a sign on their door or wall next to the room entrance instructing staff to use EBPs while providing personal care. In addition, the facility failed to ensure personal protective equipment (PPE, gloves, gowns, masks and goggles/face shields) were readily accessible for residents requiring EBP, and staff were inserviced on EBP and which residents required EBPs. The facility identified 18 residents who required EBPs, and this had the potential to affect all residents (Residents #5, #6 and #3). The census was 86. Review of the facility's Standard and Enhanced Precautions policy, dated 4/1/24, showed: -Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff consistently notified physicians when residents' high blood glucose levels exceeded the ordered parameters. The facility identified 10 residents with orders for routine blood glucose level checks, four were sampled and problems were found with two (Residents #13 and #3). The census was 86. Review of the facility Change of Condition - Observing, Reporting and Recording policy, dated 5/17, showed: -Policy: It is the policy of this home to inform the resident, the resident's physician and if indicated the resident's responsible party of the following: -A significant change in the resident's physical, mental or psychosocial status, such as a deterioration in health, mental or psychosocial status, in life-threatening conditions or clinical complications; -A need to alter treatment significantly; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident #3's physician was notified and monitoring was started after staff documented on shower review forms the resident had blisters on his/her bilateral feet. In addition, the facility failed to ensure staff initialed treatments had been completed and failed to ensure the resident wore his/her protective boots. Three residents were sampled and problems were found with one. The census was 86. Review of the facility Wound Management policy, dated 06/2020, showed: -Purpose: To provide a system for the treatment and management of residents wit wounds including pressure and non-pressure injury; -Policy: A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing; -Definitions: -Diabetic Neuropathic Ulcer: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide services and/or treatment to increase or prevent reduction of range of motion. The facility failed to maintain a measurable, goal oriented restorative nursing program, and/or exercise program, to ensure residents requiring physical assistance were assisted by staff to maintain or improve their physical abilities, per facility policy. The facility provided a list of 11 current residents who had been discharged from skilled therapy services. Of those 11, two were identified with concerns of not getting recommended restorative therapy (Residents #21 and #19). The census was 87. Review of the facility Restorative Nursing Program Guidelines, dated 6/20, showed the following: -Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's right to be free from abuse was not violated, when residents were involved in physical resident to resident altercations. Staff witnessed Resident #6 engage in a verbal altercation with Resident #5. Resident #5 then choked the neck of Resident #6, which caused bruising to the resident's neck and a sore throat. The sample was 8. The census was 87. Review of the facility's Abuse Prevention and Prohibition Program, revised 10/24/22, showed: -Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary behavioral health care services when staff did not intervene during a resident's agitated and heightened state (Resident #6) who then kicked another resident (Resident #8). The facility also failed to intervene when Residents #6 and #5 were involved in a verbal altercation that led to Resident #5 reaching out and wrapping his/her hands around Resident #6's neck. Resident #6 complained of bruising to his/her neck and a sore throat. The sample was 8. The census was 87. Review of the facility's Behavior Management policy, revised 06/2020, showed: -Purpose: To implement the most desirable and effective interventions to change, modify, decrease, or eliminate behaviors that are distressing to the resident, and/or are decreasing or negatively impacting the resident's quality of life; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's right to be free from abuse was not violated, when residents were involved in physical resident to resident altercation, in which one resident placed their hands around another resident's neck (Residents #1 and #2). The sample was 32. The facility census was 74. The facility was notified of past non-compliance on 7/2/24. Facility staff immediately intervened, notified administration, separated the residents, and provided assessment and services to the involved residents. Staff were in-serviced on abuse and neglect prevention. The deficiency was corrected on 6/29/24. Review of the facility's Abuse Prevention and Prohibition Program policy, dated 10/24/22, showed: -Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide acceptable nursing services by not directly and continuously monitoring and intervening for one resident who was in respiratory distress (Resident #1). Two therapy staff found the resident difficult to wake, breathing heavily, and would groan and open and then close his/her eyes when his/her name was called. The resident was identified not connected to the oxygen concentrator and the resident did not have his/her BiPap on. The concentrator was broken. When staff attempted to use the emergency oxygen tank (e-tank) on the back of the resident's wheelchair, it was found empty, further delaying treatment while staff went to retrieve a full e-tank. Staff applied the nasal cannula with oxygen at 4 liters from the e-tank. The resident had an order for a BiPap which was not applied when the resident was noted to be in distress. [...]

Inspectors wroteBased on interviews, record reviews, personnel file review, and review of the facility's policy, the facility failed to have two staff available during the mechanical lift transfer of one resident (Resident (R) 73). Staff failed to ensure the mechanical lift device was in working order and inspection of the device showed it had missing bolts. During the transfer, the lift collapsed. The resident was later transferred to the hospital, diagnosed with a brain bleed, underwent surgery, and expired. This had the likelihood to cause serious injury, harm or death for any of the 76 residents that could be transferred by untrained personnel. An Immediate Jeopardy was identified on [DATE] and was determined to exist starting on [DATE]. The Administrator and Director of Nursing were notified on [DATE] at 9:24 PM. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure food was not expired, skim milk was available according to physician orders, dented cans were not stored in areas of usage, dish machine concentration levels were monitored, the hood was cleaned, and food temperatures were within proper parameters and properly monitored in accordance with professional standards for food service safety for one of one kitchen for 76 census residents.

Inspectors wroteBased on interview and record review, the facility failed to have a system in place to ensure residents' individual trust fund accounts were not allowed to go into a negative balance. The facility managed funds for 46 residents. A sample of eight residents were chosen and the practice affected four residents (Residents #101, #104, #56 and #105). The census was 74. Review of the facility's Trust Policies and Management Policy, undated, showed the following: -admission Requirement Regarding Resident Trust: Upon admission the resident or resident's representative may request the facility to hold the resident's funds in the resident trust account; -General Information Regarding Responsibilities of Holding Resident Funds: [...]

Inspectors wroteBased on observations, interviews, recipe review, and pureed food guideline review, the facility failed to ensure proper pureed consistency for residents receiving pureed texture of 76 census residents.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure safe, functional, sanitary, and comfortable resident equipment for three of four residents (Residents (R) 44, R272, and R12) reviewed for wheelchair and recliner chair maintenance. The facility failed to ensure accessible Emergency Medical Services (EMS) access for 76 census residents.

Inspectors wroteBased on interview and record review, the facility failed to complete Minimum Data Set (MDS) assessments in the allotted time frame as stated in the Resident Assessment Instrument [RAI] manual for two of two residents (Resident (R) 171 and R173) reviewed.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure the Pre-admission Screen and Resident Review (PASARR) level one screen was completed prior to admission for one (Resident (R) 38) of three residents reviewed for PASARR. This created a potential failure to identify what specialized or rehabilitative services the resident needed and whether placement in the facility was appropriate prior to admission.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure care conferences were conducted for one of three residents (Resident (R) 16) reviewed for care conferences of 76 census residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure that one of two residents (Resident (R) 171) reviewed for bed rail use had a bed rail that was considered a safe design for use. This failure had the potential for the resident to become entrapped in the bed rail with a risk of severe injury and/or death with bed rail use.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure timeliness of medication administration was provided for one of one resident (Resident (R38) reviewed for late medications of 76 census residents.

Inspectors wroteBased on observation, interview, and review of manufacturer's instructions, the facility failed to ensure bed frames and rails, if present, were inspected and serviced per the Manufacturer's Instructions for Use (MIFU) to minimize the risks of bed malfunction and/or resident injury. This failure had the potential to affect any of the 76 residents who reside at the facility and use a bed.

Inspectors wroteBased on record review, interview, and review of the facility policy, the facility failed to implement and maintain a training program for lift equipment training for one Certified Nurse Aides (CNA1). This failure to train CNA1 had the potential to affect the care and services provided to any of 76 residents that might require lift transfers by CNA4.

Inspectors wroteBased on interviews and policy review, the facility failed to have a qualified Activities Director to oversee the activities department for all 76 current residents in the facility. This failure could result in all residents not being offered or participating in a resident centered and life enriching activity program.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate care and services were provided to residents with pressure ulcers (injury to the skin and underlying tissue usually over a bony prominence, as a result of pressure or friction). The facility failed to document weekly wound assessments, failed to notify the physician of new wound development delaying the resident's treatment and failed to identify a newly acquired Deep Tissue Pressure Injury (DTPI). Facility staff also failed to consistently ensure pressure ulcer treatments and interventions were performed according to the wound specialist's recommendations or as ordered and failed to ensure prevention interventions were completed as ordered. This resulted in a delay of 11 days in obtaining orders and treating a pressure ulcer for one resident (Resident #15). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities, designed to meet the interests of each resident. The facility failed to employ an activity director qualified for the position, failed to maintain an activity director in the past year for a sufficient length of time to develop and implement an effective activities program, and failed to employ sufficient numbers of activity staff. The facility failed to ensure there was a current activities schedule and failed to ensure scheduled activities occurred. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the activities program was directed by a qualified professional. This affected all residents who resided in the facility. The census was 44. Review of the Facility Assessment, revised on 6/30/21, showed: -Identify the type of staff members, other health care professionals, and medical practitioners that are needed to provide support and care for residents: The facility included the activity director as a needed staff member; -In addition to nursing staff, other staff needed for behavioral healthcare and services (list other staff positions/roles): The facility included the activity director as a needed staff member. Observation of the second floor activity calendar, on all days of the survey from 12/1/21 through 12/3/21 and 12/6/21 through 12/8/21, showed the following: -Activities for the month of: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. In addition, the facility failed to designate a RN to serve as the Director of Nursing (DON) on a full time basis. The census was 44. Review of the facility's Facility Assessment Tool, last reviewed on 6/30/21, showed: -Average daily census: 40-50; -Staff type, included: Administrator, DON, unit managers, RN, licensed practical nurses (LPNs), certified medication technicians (CMTs) and certified nursing assistants (CNAs); -Staffing plan: Total number needed, average, or range: -Licensed nurses providing direct care: 10 (agency also used); -Other nursing personnel (e.g., those with administrative duties): five; -This facility reviews and updates job descriptions annually. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. At the time of the survey, the facility assessment in use at the facility was a facility assessment for a sister facility. The census was 44. Review of the Facility Assessment Tool provided by the facility as their facility assessment, last reviewed on 6/30/21, showed: -Average daily census: 40-50; -Physical environment and building/plan needs: The facility is a large one-story community with 240 licensed skilled beds. Review of the facility layout, showed the facility had three levels. The ground level, first floor and second floor. Review of the facility's bed listing, showed a capacity of 120. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee made good faith attempts to identify and correct quality deficiencies. The facility administrator had only been at the facility for a month at the time of the survey and had not yet held a QAPI meeting. The prior administration had no current performance improvement projects identified or implemented. The survey team identify quality deficiencies for infection control, staffing, wounds, weights and activities. This failure had the potential to affect all residents in the facility. The census was 44. Review of the facility's undated Quality Assurance and Performance Improvement Committee policy, showed: -This facility shall establish and maintain a QAPI Committee that oversees the implementation of the QAPI program; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their infection surveillance program and failed to ensure the infection preventionist acted in that capacity at the facility. During the time of the survey, the infection preventionist worked as the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) coordinator on a part time basis and had not yet implemented any aspect of the infection prevention and control program. The prior infection preventionist had left employment and had last implemented the program in May 2021, nearly 6 months prior. This resulted in one resident with a wound infection not to be identified by the facility as a resident with an infection (Resident #15). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to communicate changes in their visitation policy to residents and representatives in a widespread or timely manner. This resulted in two sampled residents (Residents #41 and #34) and their family members to adhere to the more restrictive visitation policy, which denied the residents' rights to have visitors per their preference. This had the potential to affect all residents who would choose to have visitors. The sample size was 12. The census was 44. Review of the Centers for Medicare and Medicaid Services (CMS) Nursing Home Visitation Covid-19 (Revised) Memorandum, revised on 11/12/21, showed: -CMS is committed to continuing to take critical steps to ensure America's healthcare facilities are prepared to respond to the Coronavirus Disease 2019 (COVID-19) Public Health Emergency (PHE); -Visitation Guidance: [...]

Inspectors wroteBased on interview and record review, the facility failed to perform admission review (Residents #4, #34 and #244) and a yearly review (Residents #15 and #26) of code status (full code-if the heart stops beating or breathing ceases, all lifesaving methods are performed) or no code (do not resuscitate, no life prolonging methods are performed). The sample size was 12. The census was 44. 1. Review of Resident #4's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -admission date: [DATE]; -Independent with self care activities; -Diagnoses included high blood pressure and cirrhosis (late stage liver disease). Review of the resident's medical record, showed: -Resident is their own responsible party; -No order for code status; -No code status form signed by the resident; -Code status not addressed on the care plan. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents had a clean, comfortable and homelike environment when they served residents meals in Styrofoam containers and on cafeteria-style trays. The facility failed to maintain shower rooms in working order. In addition, the facility failed to ensure the walls, floors, and cove base in common areas and the medication and treatment carts were clean and in good repair. The census was 44. 1. Observations of the second floor dining room on 12/1/21 at 12:08 P.M., 12/3/21 at 9:09 A.M., and 12:41 P.M., 12/6/21 at 1:00 P.M., and 5:49 P.M. and 12/7/21 at 8:21 A.M., showed: -Residents were served trays with disposable Styrofoam food containers, plastic cups and plastic flatware; -Staff failed to remove the cafeteria- style trays from the tables after staff served food to the residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had complete, accurate and individualized care plans to address the specific needs of each resident. This affected five residents (Residents #34, #30, #35, #23 and #2) out of 12 sampled residents. The facility's census was 44. 1. Review of Resident #34's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 11/6/21, showed: -Required total assistance from staff for dressing, personal hygiene, toileting, mobility and transfers; -Always incontinent of bowel and bladder; -Diagnoses included high blood pressure, stroke and choric obstructive pulmonary disease (COPD, lung disease). Review of the resident's care plan, in use during the survey, showed: -Problem: Resident has limited physical mobility related to weakness; -Goal: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of quality for residents by failing to administer supplements as ordered by the physician (Resident #4), clarify conflicting physician orders (Resident #15) and ensuring staff did not substitute a medication for other medications, without a corresponding physician order (Resident #8). The facility failed to obtain an order for blood glucose monitoring which staff performed but also did not document (Resident #244). Additionally, staff failed to obtain and document monthly weights (Residents #26, #18, #2 and #25). The sample was 12. The census was 44. Review of the facility's undated Following Physician's Orders policy, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed ensure there are a sufficient number of skilled licensed nurses to provide nursing care to all residents in accordance with resident care plans and per the facility assessment. The facility failed to ensure a licensed nurse was on duty each shift, which resulted in the administrator having to forego her administrative duties at the facility to work as the charge nurse on the floor. The administrator's office was located on the first floor and all residents resided on the second floor. This resulted in resident's not receiving a treatment as ordered and improper documentation that residents received their ordered medications (Residents #15 and #40). The sample was 12. The census was 44. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, for one of one narcotic book reviewed. In addition, the facility failed to account for all controlled drugs when a narcotic removed from stock was not accounted for (Resident #15). The census was 44. Review of the facility's Controlled substance policy, revised December 2012, showed: -The facility shall comply with all laws, regulations and other requirements related to handling, storage, disposal and documentation of controlled substances; -Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 40 opportunities observed, nine errors occurred resulting in a 22.5% error rate (Residents #37, #25, #8 and #15). The census was 44. Review of the facility's undated Following Physician's Orders policy, showed: -The purpose of a physician's order is to communicate the medial care that a resident is to receive while in our facility, as well as to document the medications, treatments and tests that are to be/have been provided; -Once orders are obtained for a new resident, the charge nurse is to transcribe them onto a physician's order sheet and the physician then called to verify those orders. Once this is completed, the charge nurse must sign off that all orders have been verified; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals are stored and labeled in accordance with currently accepted practices, and include the appropriate expiration date. The facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys. In addition, the facility failed to ensure narcotic medications were separately locked, behind two locks. These practices affected four of four medication/treatment carts and one of one medication room reviewed. The facility identified five medication/treatment carts and one medication room in use at the facility. The census was 44. Review of the facility's Storage of Medications policy, revised April 2007, showed: -The facility shall store all drugs and biologicals in a safe, secure and orderly manor; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was served palatable and at a safe and appetizing temperature during meal service by failing to maintain the temperature of hot food at least at 120 degrees Fahrenheit (F) for two of two trays sampled. The census was 44. 1. Review of Resident #18's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 9/24/21, showed: -Cognitively intact; -Independent with eating; -Diagnoses included diabetes mellitus, high cholesterol, stroke and anxiety. During an interview on 12/1/21 at 10:49 A.M., Resident #18 said he/she doesn't like the food served at the facility. He/she can't eat the food without feeling sick and it upsets his/her stomach. The food is poor quality and it doesn't taste good. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records on each resident that are complete and accurately documented. An agency nurse contracted to work at the facility had a certified medication technician (CMT) document the administration of medications administered by the nurse (Resident #15). When working the floor as the charge nurse, in addition to having administrative responsibilities at the facility, the administrator failed to document the administration of medications (Residents #15 and #40). Staff failed to document a resident's complaint of pain, administration of medication or effective of the medication (Resident #39). In addition, staff documented the administration of medications that had not been administered (Residents #37, #25 and #8). The census was 44. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. During the time of the survey, the infection preventionist worked as the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) coordinator on a part time basis and had not yet implemented any aspect of the antibiotic stewardship program. The prior infection preventionist had left employment and had last implemented the program in May 2021, nearly 6 months prior. This resulted in one resident with a wound infection that required antibiotic use to not be identified by the facility as a resident on antibiotics (Resident #15). This had the potential to affect all residents who require antibiotic use. The census was 44. [...]

Inspectors wroteBased on interview and record review, the facility failed to designate one or more individuals with specialized training in infection prevention and control (IPC) as the infection preventionist (IP) for the facility's infection prevention control program. The census was 39. Review of the Centers for Disease Control (CDC) and Prevention's interim infection prevention and control recommendations to prevent COVID-19 spread in nursing homes, updated 2/2/22, showed: -IPC program: -Assign one or more individuals with training in IPC to provide on-site management of the IPC program; -This should be a full-time role for at least one person in facilities that have more than 100 residents or that provide on-site ventilator or hemodialysis services. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide COVID-19 vaccine boosters as requested for 10 residents (Residents #504, #35, #20, #505, #38, #403, #501, #23, #30, and #500). The sample was 18. The census was 39. Review of the facility's Resident Covid Vaccination Policy, updated 12/1/21, showed: -Policy: To protect the health and safety of our residents and staff, this facility strongly encourages the COVID-19 vaccination for residents; -Policy interpretation and implementation: -Residents will be offered the opportunity to receive the vaccine at no cost. The vaccination process is a two-step vaccination. If receiving the Moderna vaccine, the second vaccination will occur no earlier than 28 days from the initial vaccination. If receiving the Pfizer vaccine, the second vaccination will occur no earlier than 21 days from the initial vaccination. [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of verbal abuse for one resident (Residents #245). The sample was 18. The census was 39. Review of the facility's Abuse Investigation and Reporting Policy showed, undated, showed: -Policy Statement: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported; -Role of the Administrator: -If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown origin is reported, the administrator will assign the investigation to an appropriate individual; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure weekly showers were provided to two sampled residents (Residents #34 and #30). The facility also failed to have a system in place to track resident showers to ensure they were offered. The sample was 12. The census was 44. Review of the facility's Shower/Tub Bath policy, revised October 2010, showed: -Purpose: To promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin; -Documentation: The following information should be recorded on the resident's ADL record and/or in the resident's medical record: 1. The date and time the shower/tub bath was performed; 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath; 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper treatment and care to maintain good foot health for one of 12 sampled residents. The resident's feet were extremely dry with large areas of skin that flaked and peeled (Resident #30). The census was 44. Review of Resident #30's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/24/21, showed: -Moderate cognitive impairment; -Required extensive assistance from staff for mobility, dressing and personal hygiene; -Total dependence on staff for showers and toileting; -Foot problems: blank; -Diagnoses included high blood pressure, stroke, dementia and depression; -At risk for pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician's orders for weight loss prevention and nutritional needs and ensure acceptable parameters for nutritional status were maintained to prevent weight loss for three sampled residents. One resident experienced a 11.86% weight loss within a six month period and a 6.0 % weight loss within a month period (Resident #32), one resident experienced a weight loss of 8.24% within a month period (Resident #30), and one resident experienced who was fed via a tube feeding, had inconsistently documented weights and weight fluctuations (Resident #15). The census was 44. Review of the facility's Resident Census and Condition of Residents form, dated 12/2/21, showed residents with unplanned significant weight loss/gain: 12. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary behavioral health care services for a resident's psychosocial well-being when staff did not address the resident's behavior which included picking and scratching at his/her skin to the point of drawing blood. The facility failed to develop nonpharmacological interventions to help ease the resident's anxiety (Resident #35). The facility failed to notify the physician in a timely manner. The sample was 12. The census was 44. Review of Resident #35's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/8/21, showed: -Cognitively intact; -No behavioral symptoms; -No skin issues; -Independent with locomotion and eating. Required supervision with toileting and personal hygiene; -Diagnoses included high blood pressure, anxiety and depression. [...]

Inspectors wroteBased on interview and record review, the facility failed to timely provide or obtain the required services from an outside resource, for one of four residents sampled for rehab and restorative services (Resident #244). The resident was admitted to the facility with orders for physical and occupational therapy evaluations that were not completed timely. The census was 44. Review of Resident #244's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 11/30/21, showed: -admission date: 11/17/21; -Independent with activities of daily living (ADLs); -Diagnoses included diabetes, chronic obstructive pulmonary disease (COPD, lung disease), sickle-cell anemia (a group of disorders that cause red blood cells to become misshapen and break down), anxiety and depression. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post the nurse staffing information in a prominent place, readily accessible to residents and visitors. In addition, the staffing sheets maintained by the facility did not include the facility name, total number and the actual hours worked by category of staff, or the resident census. The census was 44. Observation on 12/1/21 at 1:22 P.M., on 12/2/21 at 4:00 A.M., on 12/3/21 at 5:07 A.M., and on 12/6/21 at 11:45 A.M., showed no nurse staffing information posted in a prominent place. The staffing sheets were located behind the nurse's station. During an interview on 12/6/21 11:49 A.M., the certified nursing assistant (CNA)/staffing coordinator said she does not post any nursing hours. She makes the schedule, which she keeps on a clipboard at the nurse's station. [...]

Inspectors wroteBased on interview and record review, the facility failed to fully implement their staff vaccination policy for COVID-19 by failing to obtain all the required information for one of one staff who had a medical exemption. The facility had 100% of employees fully vaccinated or with an approved exemption and had no residents with COVID-19 infections within the last four weeks. The census was 39. Review of the facility's COVID-19 Vaccine Policy, undated, included the following: -Scope: This policy applies to all employees and all non-employee personnel who perform in-person services for the organization, attend in-person organization meetings, or visit organization facilities. -Contractors and non-employees vaccination requirement: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure generally accounting principles were followed, when they did not keep resident ledgers updated, ensure all monthly bank statements were reconciled and provide documentation regarding quarterly statements. This affected 50 residents whom the facility held their funds of which 8 were sampled (Residents #15, #16, #17, #43, #56, #49, #6 and #44). The census was 71. 1. Record review of the facility resident trust fund for the previous 12 months, showed they could only provide the months of January 2019 through July 2019 of reconciled bank statements. 2. Record review of the resident ledgers, showed the following: -Resident #15's ledger had a balance of $210.03 and had not been brought current for several months as noted by the administrator (a sticky note was on the form). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure discharged residents received their money from the resident trust account timely and failed to notify third party liability (TPL) within 30 days when a resident expires. This affected six residents who left the facility or expired (Residents #240, #241, #242, #243, #69 and #244). The census was 71. 1. Review of Resident #240's Checkbook balancer, showed a starting balance of $1044.28 and an ending balance of $3073.28. During an interview on [DATE] at 1:10 P.M., the administrator said he/she was discharged on [DATE]. 2. Review of Resident #241's Checkbook balancer, showed a starting balance of $129.28 and an ending balance of $164.28. During an interview on [DATE] at 1:10 P.M., the administrator said he/she was discharged on [DATE]. 3. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe, clean, comfortable and homelike environment by failing to maintain resident rooms, equipment, walls, air conditioner covers, and water fountains in good repair. The census was 71. 1. Review Resident #19's quarterly MDS, a federally mandated assessment instrument, dated 8/18/19, showed: -Cognitively intact; -Extensive assistance required for bed mobility, dressing, and personal hygiene. Observations on 9/3/19 at 9:37 A.M. and 2:00 P.M., 9/4/19 at 1:41 P.M. and 5:44 P.M. and 9/5/19 at 12:22 P.M., showed resident in his/her bed. The controller box for the low air loss mattress hung on the foot of the bed. The controller box on and the top cover missing, exposing the electronic wires. During an interview on 9/3/19 at 9:37 A.M., the resident said he/she does not get out of bed often. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain a physician order for residents who require dialysis. In addition, the facility failed to provide a pre and post assessment of residents who are receiving dialysis service. The facility identified two residents as receiving dialysis (Resident #370 and #24). Both residents were included in the sample of 19 and issues were found with both. The census was 71. 1. Review of Resident #370's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 8/25/19, showed: -admitted [DATE]; -Brief Interview for Mental status (BIMS) score: 11, showed moderately impaired cognition; -Activities of daily living: needs assistance of one staff member for grooming, bathing, dressing and hygiene. Needs assistance of two staff members for transfers and toileting; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles, by failing to ensure all controlled substances were stored under double locks and ensuring medication and food used for medication administration was stored properly. This effected one of the two medication rooms and four of five medication/treatment/insulin carts reviewed. The census was 71. 1. Observation on 9/4/19 at 10:03 A.M., the first floor medication room, showed: -Two bottles of lorazepam intensol (narcotic medication used to treat anxiety) located inside the medication refrigerator. One bottle on a shelf in the back of the refrigerator and the other bottle located on shelf on the inside door of the refrigerator, behind only one lock. The door to the medication room locked. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' right to request, refuse and/or discontinue treatment and to formulate advance directives was followed by failing to ensure residents' code status listed on the physician order sheet matched the resident's code status form for two of 19 sampled residents (Residents #17 and #19). The census was 71. 1. Review of the facility's advance directive policy, updated August 2019, showed: -The code status order and the code status form must match; -All code status will be reviewed quarterly in care plan meetings and with significant change in condition; -If any code status updates or changes are made with the social services directives; social services will immediately notify nursing and the Director of Nursing (DON), and update the code status books and the care plan. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided by the facility meet professional standards of quality of care for 3 of the 19 residents sampled. The facility failed to obtain physician orders for two residents (Residents #60 and #3), failed to document an infection for one resident (Resident #3) and failed to follow a physician order by not obtaining a diagnostic test for one resident (Resident #50). The census was 71. 1. Review of Resident #60's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 6/18/19, showed: -Brief Interview for Mental Status (BIMS) score: of 15 out of a possible 15, which indicates cognitively intact; -Diagnoses included: Cancer, anemia and paraplegia (paralysis of the legs and lower body); -Special treatments, procedures, and programs: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide thorough personal care for two of three care observations (Residents #53 and #66). The facility also failed to provide grooming and nail care to one resident (Resident #50) of 19 sampled residents. The census was 71. 1. Review of facility's perineal care (cleansing the front of the hips, between the legs and buttocks) policy, revised 10/2010, showed: -Purpose: To provide cleanliness and comfort to the resident, to prevent infection, skin irritation and to observe the resident's skin; -Procedure: -Wet the washcloth and apply soap or skin cleansing agent; -Wash the perineal area, wiping from the front to the back; -Separate the skin folds and wash downward from the front to the back. Wash moving from inside to the outside including the thighs, alternating from side to side and use downward strokes. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident by failing to provide documented one to one individual activities to three of 19 sampled residents. In addition, the facility failed to adequately document the activities provided and the length of time of the activity (Residents #19, #52, and #66). The census was 71. 1. Review of the facility's activity calendar, showed one to one activities was scheduled on the following dates and times: -Monday through Friday at 5:30 P.M.; -Saturday and Sunday at 11:30 A.M. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for two of six resident's investigated for pressure ulcers resident's (Residents #19 and #169). The sample was 19. The census was 71. 1. Review Resident #19's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/18/19, showed: -Cognitively intact; -Extensive assistance required for bed mobility, dressing, and personal hygiene; -Diagnoses included high blood pressure, multiple sclerosis (MS, neurological disorder), depression, osteomyelitis (bone infection), bacterial infection, and vitamin D deficiency; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion by failing to follow the physician's order for restorative therapy, for one of 19 sampled resident (#50). The census was 71. Review of Resident #50's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/28/19, showed: -Moderate cognitive impairment; -Extensive one person physical assist required for bed mobility, transfer, dressing, toilet use and personal hygiene; -No restorative therapy provided; -Diagnoses included anemia, high blood pressure, blood clots and diabetes. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents environment remains as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents by failing to ensure medications were secured and not accessible to residents, ensure proper transfer techniques were used during resident transfers, and failed to follow physician's orders for tubi-grips (tubular bandage) used to prevent injury, for three of 19 sampled residents (Residents #15, #53 and #50). The census was 71. 1. Review of the facility's storage of medication policy, revised 4/2017, showed: -Policy statement: The facility shall store all drugs and biologicals in a safe, secure and orderly manner; -Policy interpretation and implementation: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status and offer a therapeutic diet when there is a nutritional problem and failed to follow physician's orders and provide additional meal supplements as ordered for one resident with a significant weight loss (Resident #44) out of 19 sampled residents. The census was 71. Review of Resident #44's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/22/19, showed: - Severe cognitive impairment; -Set up help and supervision required with eating; -Wheelchair for mobility; -Weight loss of 5% or more over the last month or 10% or more over the last six months; -No swallowing disorders; -Weight 120 pounds (lbs.); -Nutritional approach: None; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to follow their policy for one resident who was on isolation out of 19 sampled residents (Resident #67). The census was 71. Review of the facility's Isolation-Notices of Transmission-Based Precautions policy, showed: -Policy Statement: -Appropriate isolation notices will be used to alert staff of the implementation of transmission-based precautions, while protecting the privacy of the resident; -Policy interpretation and implementation: -When transmission-based precautions are implemented, an appropriate sign (example: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents have the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility by failing to post in a place readily accessible to residents, and family members and legal representatives of residents, the most recent plan of correction for the survey of the facility. In addition, the facility failed to post notice of the availability for any individual to review upon request the reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility. The census was 71. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff treated residents in a respectful manner by posting resident care signs in a resident room (Resident #36) and failed to knock on residents' doors before entering. In addition, the facility staff failed to speak in a dignified manner in the presence of residents. The census was 71. 1. Review of Resident #36's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/8/19, showed: -Clear speech at times; -Usually understands; -Rarely/never understood; -Diagnoses included heart failure, hypertension (high blood pressure), pneumonia, hyperlipidemia (high cholesterol), seizure disorder, diabetes and depression. Observations on 9/4/19 at 1:33 P.M. and at 5:18 P.M., 9/5/19 at 7:40 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident assessment accurately reflected the residents' status for three of four residents who had a resident assessment completed after the start of hospice services (Residents #28, #17 and #66). The census was 71. 1. Review of Resident #28's medical record, showed the resident received hospice services since 7/19/18. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/19/19, showed: -Received hospice services; -Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months: No. 2. Review of Resident #17's medical record, showed he/she had been admitted to hospice services on 6/17/19. Review of the resident's quarterly MDS, dated [DATE], showed: -Received hospice services; [...]