Pruitthealth - Magnolia Manor

Inspectors wroteBased on observations, staff interviews, and the review of the facility policy titled, How to Puree Foods, the facility failed to ensure pureed foods were prepared using standardized recipes and in accordance with accepted professional food service standards for residents requiring texture-modified diets. This deficient practice had the potential to affect three residents receiving pureed diets and placed them at risk of receiving foods that were not prepared to the prescribed consistency, which could compromise safe consumption and compliance physician-ordered diet requirements. Findings Include:Review of the facility's policy titled, How to Puree Foods, undated, documented under the section Preparation Steps section 1, Depending on the resident's dietary restrictions, follow the proper recipe to prepare the regular consistency food item. [...]

Inspectors wroteBased on observations, resident and staff interviews, record reviews, and review of the facility policy titled, Residents' Rights, the facility failed to provide care in a manner that maintained each resident's dignity and respect for one of 40 sampled residents(R) (R38). This deficient practice had the potential to compromise the residents' rights to be treated with dignity and respect. Findings Include:Review of the facility policy titled, Residents Rights, with a revision date of 12/01/2023 documented, It is policy of the healthcare center to promote and protect the rights of patients/ residents residing in the center. In addition, all patients/ residents and their responsible parties must sign a written statement of acknowledgement and given a copy of the center's patients/ resident rights and responsibilities . Procedure . 2. [...]

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Labeling, Dating, and Storage, the facility failed to discard expired items, failed to label and date items in one reach-in refrigerator, one walk-in cooler, and one dry storage area. The facility also failed to ensure food was delivered to residents receiving meals in one of three dining rooms in a sanitary manner related to proper hand washing and sanitation during the delivery of food. This deficient practice had the potential to affect eight residents eating in the 500-hall dining room. The failure had the potential to promote foodborne illnesses associated with bacterial growth and cross-contamination for 89 of 91 residents who received an oral diet.

Inspectors wrote2. Record review revealed R16 was admitted on [DATE] with diagnoses of anxiety and dementia, with dementia being the primary diagnosis. Resident had an order for psychiatric services and received psych counseling services for anxiety during her stay. Record review of Physician Order Form (POF) dated October 2024 revealed R16 received the following medications, alprazolam (Xanax) 1 mg tablet twice a day (order start date 5/9/2024). Resident also had an order for Effexor 75 mg twice a day (start date 6/1/2023). Record review revealed no PASARR Level ll. Review of progress notes revealed R16 had a history of displaying irrational behaviors since admission as defined/documented in the care plan. [...]

Inspectors wroteBased on staff interviews and record reviews, the facility failed to provide evidence that nutrition assessments were completed by the Registered Dietitian (RD) for three of three residents (R) (R66, R44, and R46). Specifically, they failed to complete an admission nutrition assessment for one resident (R66), and follow-up assessments for two residents (R44 and R46), who were identified with weight loss.

Inspectors wroteBased on observations, interviews, record reviews, and review of the facility's policy titled, Medication Administration: General Guidelines, the facility failed to maintain effective infection control practices for three of four residents (R) (R21, R31, R34) during medication administration. Specifically, the facility failed to maintain infection practices for one resident (R21) during a fingerstick blood sugar check, during inspection of the PPE (personal protective equipment) cart that was not maintained in a sanitary manner, during observation of dining, observation in resident rooms where dirty IV (intravenous) tubing was left, and during resident screening where staff were seen sitting on resident's beds. The deficient practices had the probability to increase the potential for cross-contamination and spread of infection.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to provide care in a manner that maintained or enhanced resident's rights, dignity and respect. Specifically, the facility failed to ensure facial hair was removed when requested for one female resident (R) (R36) of 28 sampled residents.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to ensure unauthorized and expired medications were not stored at the bedside of one of 28 residents (R) (R16). The deficient practice had the potential to allow unauthorized access of unsecured medications to residents and visitors.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility's policy titled, Advance Directives, the facility failed to provide residents and/or representatives written information with options regarding their right to accept or refuse medical or surgical treatment for four Residents (R) (R52, R65, R15, R29) out of a sample size of 28 residents reviewed. This failure denied the residents and/or representatives the opportunity to have choices and preferences with their health care decisions and formulating an Advance Directive.

Inspectors wrote[NAME], [NAME] Based on observations, staff interviews and record reviews, the facility failed to ensure the facility was maintained in a safe, clean, and homelike environment on three of eight halls (Hall 600, 700, and 800). Specifically, the facility failed to replace a stained pillow for R53, failed to ensure the common area on two halls were free of trip hazards from electrical sockets on the floor on the 700 and 800 halls, failed to repair one cracked toilet on the 600 hall, and failed to maintain the sanitation of three water fountains covered in a thick beige/white hard scale substance. The deficient practice had the potential to cause an unsafe and unsanitary environment.

Inspectors wroteBased on interview and review of the facility's policy titled, Grievances: Healthcare Centers, the facility failed to ensure residents were informed of the name of the Grievance Official and how to file a grievance. Spceifically, the facility failed to ensure that all residents who resided in the facility were knowledgeable of the grievance process.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled, Care Plans, the facility failed to develop and/or implement a comprehensive care plan for five of 28 sampled residents (R) (R36, R52, R56, R25, R65). Specifically, the facility failed to implement care plans for activities of daily living (ADL) and incontinence care for R36 and R52; psychiatric services for R25 and R65; and vision services for R56. These deficiencies had the potential to adversely affect their quality of care and services, as well as their quality of life.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to provide Activities of Daily Living (ADL) care for six of six residents (R) (R36, R52, R72, R29, R56, and R23 ) according to the residents care needs. Specifically, the facility failed to ensure that fingernails were trimmed and clean for (R72, R29, R56, R23); failed to ensure incontinence care was provided for R52, and failed to provide a bath/shower on the weekend for R36.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility's policy titled, Specialty Services: Dental Services Vision Services, Podiatry Services, Hearing Services, and Mental Health, the facility failed to obtain vision services for two of 28 residents (R) (R56 and R78).

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to follow an Occupational Therapy (OT) Restorative Nursing Program (RNP) recommendation for orthotic application (splint) for one of eight sampled residents (R) (R78) reviewed for ROM (Range of Motion) and mobility. The deficient practice had the potential to result in progression of contractures.

Inspectors wroteBased on observations, staff interviews, record reviews, and review of the facility's policy titled, Occurrence Reduction Program, the facility failed to ensure an environment free from potential accident hazards by failing to properly secure oxygen (O2) tank for one of 10 residents (R) (R16) receiving oxygen therapy. In addition, the facility failed to remove aerosol cans from the bedside for one resident (R47); and failed to provide adequate supervision for residents assessed as high risk for falls for three of 10 residents (R34, R75, and R65).

Inspectors wroteBased on observations, resident and staff interviews, and review of the facility's policy titled, Oxygen Administration, the facility failed to ensure two of 10 residents (R) (R16 and R11) receiving oxygen therapy, oxygen tubing and nebulizer masks were covered, and did not rest on the floor. The deficient practice had the probability to increase the risk of infection for residents receiving oxygen therapy.

Inspectors wroteBased on resident and staff interviews, record reviews, and review of the facility's policy titled, Specialty Services: Dental Services, Vision Services, Podiatry Services, Hearing Services, and Mental Health, the facility failed to obtain mental health services for three of three sampled residents (R) (R61, R65, and R25). The deficient practice had the probability to affect the overall mental health status of residents requiring psychiatric services.

Inspectors wroteBased on resident and family interviews, staff interviews, record review and review of facility policy titled, Resident Grievances, the facility failed to ensure residents' concerns that were presented in resident council meetings were followed through the grievance process; the facility also failed to file a grievance and investigate for one of two residents (R)(R1) after being informed by another state office. The facility census was 93 residents.

Inspectors wroteBased on resident interviews, staff interviews, record review, and review of the facility policy titled, Resident Trust, the facility failed to include cash transactions for one of 48 residents (R1); the facility also failed to open and put cash into a trust account for one of 48 resident (R2). The facility census is 93.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of property, the facility failed to protect two Residents (R1, R2) from exploitation of their cash money locked in a facility safe. The facility census was 93.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Abuse Prevention & Reporting, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act of timely reporting to the State Agency an incident in which one of two residents (Resident 1 (R1) money was stolen from a facility safe. The facility census was 93.

Inspectors wroteBased on observation, resident and staff interviews, resident and staff interviews, and review of the facility policy titled, Care Plans, the facility failed to develop a comprehensive person-centered care plan with goals and interventions for one resident (R) R#81, receiving intravenous (IV) antibiotics of 35 sampled residents reviewed for care plans.

Inspectors wroteBased on observation, resident and staff interviews, resident and staff interviews, and review of the facility policy titled, Care Plans, the facility failed to update care plan for one resident (R) R#81, related to indwelling catheter usage, of 35 sampled residents reviewed for care plans.

Inspectors wroteBased on observations, interviews, record review, and review of facility policy titled Oxygen Administration dated 11/22/21 the facility failed to ensure oxygen (O2) tanks were secured in three resident (R) reviewed R#27, R#33, and R#50 rooms of 18 residents receiving oxygen.

Inspectors wroteBased on observation, staff interview, and review the policy titled, Oxygen Administration the facility failed to obtain a Physician's order for oxygen for one resident (R) R#53, 18 residents that received oxygen therapy.