Magnolia Manor - Inman

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to ensure the physician documented that the Clinical Pharmacist (CPh) recommendations regarding the use of a PRN (as needed) medications were reviewed and failed to document the action taken or not taken to address the irregularities for one (Resident (R)13) of five residents reviewed from a sample of 43 residents. This failure had the potential to lead to unwarranted medication side effects or improperly treated symptoms.Findings include:Review of the facility policy titled Pharmacy Services Policies and Procedures dated 04/17/24 revealed, The facility will ensure that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, psychological wellbeing. The Facility will comply with all Federal, State and Local regulations regarding unnecessary drugs . 6. For non-Urgent recommendations, the Facility and Attending Physician must address the recommendation(s) in a timely manner that meets the needs of the resident. Upon receipt of the written Consultant Pharmacist Report of non-urgent recommendations, the DON or facility designee shall provide the report to the attending physician(s) or their designee during their next regularly schedule facility visit or within 5 business days, whichever should come first . 9. If the Attending Physician or their agent fails to address a recommendation or document a rationale for declining a recommendation: A. The Director of Nursing or facility designee will alert the Medical Director where MRR's [Medication Regimen Review] are not addressed timely or completely by the attending physician. Review of R13's Resident Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed R13 was admitted to the facility on [DATE] with diagnosis including but not limited to anxiety. Review of R13's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/11/25 and located under the MDS tab of the EMR revealed R13 had severe cognitive impairment as assessed by staff. Review of R13's Orders located under the Orders tab of the EMR revealed a Prescription Order dated 06/17/25 for lorazepam (antianxiety medication) 1 milligram (mg) every 6 hours as needed with the End Date on the Prescription Order indicated Open Ended; an order for buspirone (antianxiety medication) 7.5 mg three times a day dated 06/10/22 with an End Date of Open Ended; and Lexapro (escitalopram) (antidepressant medication) 10 mg three tablets once a day dated 12/18/24 (renewal date) and an End Date of Open Ended. Review of R13's Note to Attending Physician/Prescriber signed by the facility's nurse practitioner (NP) on 07/24/25 revealed the CPh had recommended, Resident has a PRN order for an anxiolytic, lorazepam 1 mg Q6H (every 6 hours) which has been in place for greater than the 14-day observation period without a projected stop date or duration of therapy . Please consider discontinuing the PRN order or if the medication cannot be discontinued at this time, CMS requires that the prescriber document the indication for use, the intended duration of therapy and the rationale for the extended time period. On the Note to Attending Physician/Prescriber the NP response read, No longer on board. Review of R13's Note to Attending Physician/Prescriber dated 08/27/24 revealed the CPh had recommended This resident is currently receiving antidepressant therapy with escitalopram 20 mg QD. This dose has been in place for some time, and a review of the resident chart does not reflect a worsening of depression. To reach the minimal effective dose, may I suggest an attempt at a dose reduction? The facility NP responded on 09/16/24 with Resident on hospice. All med [medication] changes made by them.Review of R13's Note to Attending Physician/Prescriber dated 08/27/24 revealed the CPh had recommended This resident is currently receiving antidepressant therapy with buspirone 7.5 mg TID. This dose has been in place for some time, and a review of the resident chart does not reflect a worsening of depression. To reach the minimal effective dose, may I suggest an attempt at a dose reduction? The facility NP responded on 09/10/24 with Resident on hospice. All med changes made by them.Review of R13's Resident Documents in the EMR revealed no other provider communication related to the CPh's recommendations. Review of R13's Progress Notes revealed no other provider communication related to the CPh's recommendations.Review of R13's hardcopy hospice provider notes in the facility hospice binder revealed no notes related to the CPh's recommendations.During an interview on 08/13/25 at 3:15 PM, the Director of Nursing (DON) stated the pharmacy recommendations are emailed to her and then forwards to the facility NP for review. For residents on hospice services, the hospice agency providers managed the medications and so should receive the pharmacy recommendations. During an interview on 08/13/25 at 4:20 PM, the Team Coordinator (TCAH) for the hospice agency stated their agency did not receive pharmacy recommendations from the facility for R13. The TCAH stated normally a facility sends the pharmacy recommendations directly to the agency, then they are sorted and sent to the appropriate provider for consideration.During an interview on 08/13/25 at 4:50 PM, the CPh stated if the resident was under hospice services, the hospice provider was responsible for medication management and should have received the pharmacy recommendations. The CPh stated if the hospice provider does not respond, then it was the facility's responsibility to then communicate the recommendations to the facility providers for consideration.During an interview on 08/14/25 at 5:33 PM, the facility NP stated she did not manage medications for residents on hospice services. She expected the facility staff to forward the recommendation to the hospice provider. During an interview on 08/14/25 at 3:30 PM, the DON stated the lorazepam, escitalopram and buspirone pharmacy recommendations should have been communicated to the hospice provider for consideration.During an interview on 08/14/25 at 3:45 PM, Unit Manager (UM)1 stated the hospice provider should have been contacted either over the phone or on their next visit because once a resident is on hospice services it was the hospice provider that manages the medications. She reviewed R13's EMR and stated there were no notes indicating the facility had communicated the pharmacy recommendations to the hospice agency for consideration after the facility NP responded that she was not managing R13's medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure the residents' code status preference was honored in that the physician's order did not match the code status preference on the residents' Physician Order for Life Sustaining Treatment (POLST) document for two (Resident (R)9 and R77) of five residents reviewed for code status. This failure had the potential to result in the residents not receiving lifesaving cardiopulmonary resuscitation (CPR).Findings include:Review of the facility's policy titled Advance Directives revised on [DATE] revealed, The facility's staff will inform the patient/resident about formulating an advance directive and will maintain written policies and procedures regarding advanced directives and Physician Order for Life Sustaining Treatment (POLST), or similar documents where applicable, including information on decisions involving resuscitative services and life-sustaining treatments.8. Obtain primary physician orders for the patient/resident advance directives, A POLST and some of the other forms are recognized as a valid physician's order, where applicable under state law. 9. POLST - Physician Orders for Scope of Treatment. All are the same concept as the POLST (Physician's Orders for Life- Sustaining Treatment) paradigm.1. Review of R9's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] located in the Resident Assessment Instrument (RAI) tab of the electronic medication record (EMR) revealed an admission date of [DATE], a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R9 was cognitively intact, and diagnoses of tracheostomy status, chronic respiratory failure, unspecified whether with hypoxia or hypercapnia, and schizoaffective disorder, bipolar type.Review of R9's POLST dated [DATE] located in the EMR under the Resident Document tab revealed Attempt Resuscitation/CPR and Full Treatment were checked, and the form was signed by R9.Review of R9's Progress Note dated [DATE] located in the EMR under the Progress Note revealed Code Status: Full Code/Scope of Treatment. Review of R9's Orders dated [DATE] located in the EMR under the Order tab revealed Code Status: DNR [do not resuscitate]. Review of R9's Care Plan dated [DATE] located in the EMR under the RAI tab revealed Advanced Care Planning I DNR with an approach of Resident has completed the following advanced directives (x) DNR.During an interview on [DATE] at 5:40 PM, R9 was asked if her heart should stop, did she want someone to give her CPR to start it again. R9 stated, Yes, she wanted CPR.During an interview on [DATE] at 5:45 PM, the Social Services Assistant (SSA)2 was asked should the POLST and physician's order for code status match. The SSA2 stated, Yes. SSA2 was asked why R9's POLST code status did not match R9's physician order for code status. SSD2 reviewed the EMR and stated she wasn't aware of the discrepancy.During an interview on [DATE] at 5:50 PM, Licensed Practical Nurse (LPN)1 was asked what happens if a resident codes (found without a pulse). LPN1 stated she would check the Medication Administration Record (MAR) for the resident's code status and follow the physician's order. LPN1 was asked if they had a hard chart she would reference or check the POLST form. LPN1 stated there were no hard charts to check. LPN1 stated she was agency, and she didn't know what a POLST form was or where to find it.During an interview on [DATE] at 5:52 PM, LPN2 was asked what she would do if R9 coded. LPN2 stated she would check the code order in the computer and have someone else check the POLST form as she wasn't sure where it was located. 2. Review of R77's quarterly MDS with an ARD date of [DATE] located in the RAI tab of the EMR revealed an admission date of [DATE], a BIMS score of 15 out of 15, indicating R77 was cognitively intact and diagnoses of heart failure, chronic kidney disease, and hypertension. Review of R77's POLST dated [DATE] located in the EMR under the Resident Document tab revealed Attempt Resuscitation/CPR and Limited Treatment were checked. The form was signed by R77.Review of R77's Care Plan dated [DATE] located in the EMR under the RAI tab revealed Advanced Care Planning: Code Status DNR.Review of R77's Orders dated [DATE] located in the EMR under the Order tab revealed Code Status: DNR.During an interview on [DATE] at 6:14 PM, R77 was asked if her heart stopped, did she want someone to use CPR to start it again, as that was on her paperwork. R77 stated, Yes, CPR is okay, but not much more. R77 then asked if her paperwork was correct. R77 was informed that her POLST did list her wishes for CPR with limited treatment. During an interview on [DATE] at 6:52 PM, the Director of Nursing (DON) was asked how staff initially obtained a resident's code status. The DON stated upon admission, whether a resident came from the hospital or home, they would have a discussion with the resident or their representative about advance directives. The DON stated the social worker completes the POLST, and the resident or representative and physician sign the form. The DON stated a POLST should be signed regardless of whether a resident was a full code or DNR. The DON further stated for new admissions the unit manager adds the order to the EMR or the floor nurse if the code status changes during their stay. The DON stated the code status order should include a POLST and the physician's order. The DON was asked if a resident coded/found not breathing, what should staff do? The DON stated staff should check the code status in the order and at the top of the EMR profile. The DON was asked if the POLST should be checked as well or was it necessary. The DON stated, Not if they are a DNR, and they know that because they had already seen the order. The DON was asked if she was aware that the POLST did not match the order for R9 and R77. The DON stated, No. The DON was asked if it was possible that the POLST and code status order did not match. The DON stated, Yes, if someone made a mistake. The DON was asked how the mistake could be prevented. The DON stated, Make sure they match. The DON confirmed staff need to ensure the POLST and the code status order reflect the resident's wishes. During an interview on [DATE] at 7:20 PM, SSA1 was asked how staff initially obtained a resident's code status. SSA1 stated the resident, or their representatives, are asked, and their decision is added to an order and the face sheet. SSA1 stated once the order was in the EMR, the POLST was uploaded into the EMR.

Based on interview, record review, and facility policy review, the facility failed to report blood sugar levels (BS) below 60 mg/dl (milligrams per deciliter) to the physician and failed to follow physician orders to hold insulin when the BS was below 100 mg/dl for one (Resident (R)87) of one resident reviewed for laboratory services.Findings include:Review of the facility policy titled Physician and other Communication/Change in Condition, revised 05/05/23, revealed, To improve communication between physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition, and provide guidance for the notification of patients/residents and their responsible party regarding changes in condition. Procedures: 1. Complete assessment of the patient/resident which may include but is not limited to: . E. Blood Glucose . 3. Notify the physician of the change in medical condition. The nurse will document all assessments and changes in the patient's/resident's condition in the medical record.Review of the facility policy titled Laboratory Testing, revised on 05/05/23, revealed, . 2. The attending physician or physician extender shall be promptly notified of abnormal, critical, or stat [immediately] test results. 3. The charge nurse receiving the test results shall be responsible for notifying the physician or physician extender of such test results in a timely manner.Review of the facility policy titled Medication Management Program, revised on 01/15/25, revealed, . 3. Prior to administering medications, the nurse is responsible for: A. Obtaining and recording any necessary vital signs . 5. The authorized staff member validates the following information is documented on the MAR [Medication Administration Record]: A. Correct physician's order and diagnosis for each medication . 13. The authorized staff member administers medications according to accepted standards of practice and incompliance with regulatory requirements.Review of R87's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/04/25, located in the Resident Assessment Instrument (RAI) tab of the electronic medication record (EMR), revealed an admission date of 01/18/21 and a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating R87's cognition was severely impaired and had a diagnosis to include but not limited to diabetes mellitus.Review of R87's Orders located in the EMR under the RAI tab revealed the following order: Lantus Solostar U-100 Insulin (insulin glargine) insulin pen; 100 unit/mL [millilitre] (3 mL); amt [amount]: 16 units; subcutaneous Special Instructions: Hold if fsbs [finger stick blood sugar] < [less than] 100 Every 12 Hours 08:00 AM, 08:00 PM, dated 07/10/25. Notify provider if less than 60 or greater than 450. Once A Day 06:00 AM, originally ordered on 07/26/22.Review of R87's Care Plan revised on 08/04/25, located in the EMR under the RAI tab revealed, [R87] is at risk for Hyper/Hypoglycemia secondary to Diabetes. Interventions included Medication adjustment per provider order and Give meds [medications] per order, labs [laboratory] per order and report abnormals [sic] to MD [physician].Review of R87's Progress Note dated 07/10/25, located in the EMR under the Progress Note tab revealed NP [Nurse Practitioner] increased resident's Lantus to 16u [unit] from 14u because of elevated A1C (a blood test that measures a person's average BS levels over the past 2-3 months).Review of R87's Progress Note dated 08/13/25, located in the EMR under the Progress Note tab revealed bg [blood glucose] low, snack x2 given.Review of R87's August 2025 Medication Administration Report (MAR) located in the EMR under the Order tab revealed at 6:00 AM, nine blood sugar (BS) levels were documented to be below 100 mg/dl and on one occasion no BS was documented. Insulin was documented as administered at 8:00 AM on these days. No BS was recorded for the PM insulin administration. Furthermore, BS levels below 60 included no documentation the physician was notified.These included:On 08/02/15 at 6:00 AM at 62 mg/dl,On 08/05/25 at 6:00 AM at 76 mg/dl,On 08/06/25 at 6:00 AM at 63 mg/dl,On 08/07/25 at 6:00 AM at 61 mg/dl,On 08/08/25 at 6:00 AM at 67 mg/dl,On 08/09/25 at 6:00 AM at 56 mg/dl,On 08/10/25 at 6:00 AM no BS was recorded,On 08/11/25 at 6:00 AM at 78 mg/dl,On 08/12/25 at 6:00 AM at 69 mg/dl,On 08/13/25 at 6:00 AM at 49 mg/dl.During an interview on 08/13/25 at 2:06 PM, Regulatory Specialist (RS) was asked if R87's insulin was administered when her BS was documented below 100, when her order instructed the nurse to not administer the insulin if her BS was below 100. RS was also asked why the BS was blank for 08/10/25 but insulin was documented as given. At 3:48 PM the RS stated she didn't find anything more than what was reviewed earlier for R87.During a telephone interview on 08/13/25 at 5:10 PM, the Clinical Pharmacist (CPh) was asked about R87's insulin being administered without a BS check in the PM when the insulin was administered twice daily, in the AM and PM. The CPh stated, It's best practice to match dosing schedule with the sticks.During an interview on 08/13/25 at 5:45 PM, Licensed Practical Nurse (LPN)1 was asked if she administered R87's insulin on 08/13/25, 08/12/25, and 08/11/25. LPN1 stated, Yes. LPN1 was asked if R87's insulin order included to not administer insulin if R87's BS was less than 100. LPN1 then reviewed the EMR and confirmed the order. LPN1 was shown the BS levels on the MAR were below 100 on 08/13/25, 08/12/25, and 08/11/25 and LPN1 was asked if the insulin should have been administered. LPN1 stated she didn't check the BS as it was another nurse at 6:00 AM. LPN1 stated she rechecked R87's BS before she gave the insulin on 08/13/25 this morning at 8:00 AM and it was okay to administer. LPN1 stated, however, she didn't document her BS because there was no place to record it.During an interview on 08/14/25 at 1:45 PM, the Director of Nursing (DON) was asked about R87's insulin given when the BS was low and the order instructed to not administer if the BS was below 100. The DON reviewed the EMR and confirmed it was not followed, stating, The order was a bad one. The DON stated she was not aware of R87's BS at 49 on 08/13/25 but confirmed the physician should have been called. The DON stated a new order for BS was given.During an interview on 08/14/25 at 5:28 PM, Unit Manager (UM)2 stated the nurse who took the BS should have called the physician. UM2 was asked what the BS parameters were for R87. UM2 stated, the parameters were 60/450 but the order was discontinued on 08/13/25 for unknown reasons.During a telephone interview on 08/14/25 at 6:29 PM, the Nurse Practitioner (NP) was asked if she had been informed about R87's BS at 49 on 8/13/25. The NP stated she had not been informed. the NP was asked if she should have been notified about the BS. The NP stated, Yes, she should have received a call. The NP stated the nurses should be calling her for BS less than 60 or greater than 450. The NP stated the nurse was supposed to check R87's BS twice daily because the Lantus order is every 12 hours, and this included holding the insulin if BS was less than 100. The NP was asked if she was aware of R87's BS at 56 on 08/09/25 and the NP stated she was not aware. The NP stated she was not aware of any time the insulin was given when R87's BS was less than 100, and she was also not aware R87's BS parameters were discontinued on 08/13/25.During a follow up interview on 08/14/25 at 6:37 PM, the DON was asked about R87's BS parameters being discontinued. The DON stated she was not aware, and the parameters should not have been discontinued.

Based on review of the facility policy, record review, and interview, the facility failed to report an allegation of elopement that occurred on 04/28/25. Specifically, Resident (R)1 eloped two separate times from the facility on 04/28/25 and the facility failed to report the elopement.
Findings include:
Review of the facility policy titled Elopement with a complete revision date of 11/01/2017, documents, To safely and timely redirect patients/residents to a safe environment. The Director of Nursing or designee notifies the Administrator/designee and notifies the appropriate agencies, attending physician, and the patient's/resident's legal representative. The Facility leadership contacts their Regional [NAME] President of Operations and their Clinical Services Director for recommendations at the time of the elopement.
Review of R1's Progress Notes dated 04/28/25, revealed, 3:29 PM-Resident was seen going out of door 5 she was immediately followed by staff we did not see her anywhere in the parking lot I went back in to get more nurses once back outside I saw the resident laying in the middle of the road I called for her to be sure it was her as it was dark and I could not see after getting no response I went in the road and it was [R1] so me and 2 other nurses talked to her and got her to get up and follow us inside where she continued to try to escape so me and a certified nursing assistant (CNA) kept her at the nurses station and when we no longer could do so she got to her room where a CNA sat outside the door to watch her. The DON and unit manager were alerted at the time of the incident.
Review of R1's Progress Note dated 04/28/25 at 7:09 PM, revealed, Resident noted missing after alarm was sounding on unit 2 and staff checked her room. She was noted walking in the staff parking lot on the side of the building heading to the front of the building. After running to catch up with her, she put herself on the ground and started yelling and kicking staff as several assisted her onto a wheelchair (WC), and she slid herself back onto the ground. The Nurse Practitioner (NP) and unit manager notified and per NP order received to transport resident to the ER for evaluation. Resident remained alert, no injuries noted at that time.
Review of the INTERACT Nursing Home to Hospital Transfer Form/Situation Background Assessment Recommendation (SBAR) dated 04/28/25 at 4:43 PM, from Magnolia Manor, unit 2. The reason for transfer revealed, Elopement, Combative. Usual functional status- Ambulates independently. Risk alerts- Agitation with risk to harm to self or others, may attempt to exit, and seizures.
An attempt to contact R1's Resident Representative (RP) on 06/03/25 at 12:02 PM, was unsuccessful, the number was not in service.
During an interview with the Administrator on 06/03/25 at 12:11 PM, revealed he has been in his role since last week, 05/28/25. The Administrator stated he was unaware of this event, and he has no facility investigation related to R1 and the events that occurred in April 2025.
During a phone interview with Licensed Practical Nurse (LPN)1 on 06/03/25 at 12:38 PM, revealed she came in at 7 AM on 04/28/25, she was getting a report from LPN2 related to R1's elopement that occurred at 1:00 AM, and that R1 went out the back door on unit 2, was found in the street lying on the ground (main road). LPN1 revealed that while getting the report, R1 successfully eloped again around 7:00 AM. The alarms were going off, and another staff member went and checked R1's room; she was not there. Staff started looking for her, and R1 was found in the parking lot within line of sight and was redirected back to the building. LPN1 stated that CNA1 was able to redirect R1 into the building via a non-mechanical wheelchair. LPN1 further stated protocol is to report to the Director of Nursing (DON) and Administrator. LPN1 confirmed that R1 successfully eloped the building twice on 04/28/25.
During an interview with LPN2 on 06/03/25 at 1:04 PM, LPN2 stated that on 04/28/25, around midnight, R1 was wandering throughout the building. That night, she exited door 5, which is located in unit 2, which is 4-5 rooms down from her room. The alarm goes off. She and the agency CNA (unable to recall name) split up and looked for her. R1 was not found on the premises. Staff came back in the building, got more staff, 2 nurses from stations 3 & 4, and went back out the front door. LPN2 stated she saw a dark shadow on the main road. LPN2 stated she called R1's name out, and she would not respond. LPN2 walked up to the dark shadow and confirmed that it was R1; she was found alert/responsive and ignoring LPN2. LPN2 stated staff tried talking to her, told her she can't lie in the middle of the road because it's dark and dangerous. LPN2 stated that following the incident, the unit manager was contacted, and DON, who instructed her to do a body audit, a full skin assessment. No injuries were noted following the incident. A progress note and Sbar were completed. R1 did not go out to the hospital at that time; however, she was sent after she eloped again at 7:00 AM, for behaviors. LPN2 concluded she was told to do a witness statement and which was given to the previous Administrator.
An attempted phone interview with the previous Administrator on 06/03/25 at 1:45 PM, was unsuccessful, call forwarded to voicemail. A detailed message was left for a return phone call.
During an interview with the Unit Manager (UM) on 06/03/25 at 1:57 PM, revealed, I am the Unit Manager. However, I have no knowledge about this. I got notified by [LPN2] that [R1] got out at 1:00 AM, I was not physically in the building. I told her to notify the DON and to make sure the resident was brought back in the building, and someone was to sit with the resident until we can come together as a team and see how the situation can be corrected, and she became 1 on 1.
During an interview with the Director of Nursing (DON) on 06/03/25 at 3:35 PM, revealed she is aware of the incident. The DON stated she was notified when she arrived for her shift. The DON was told R1 got out, staff heard the door, staff looked for her, and staff found her lying on the main road. The DON stated she was also told R1 eloped again, right before she arrived for her shift. The DON stated she had notified her Administrator at the time and thought the situation was reported. The DON also stated she and the Administrator at the time spoke with the Nurse Consultant, who told them that the incident was not to be reported because there is a fine line between federal and state regulations. The DON followed the chain of command. The DON stated she did what she could to protect the resident at the time. The DON stated the facility should have reported both incidents. The DON further stated she cannot override the chain of command; the Administrator at that time could have overridden the Nurse Consultant's decision.
During an interview with the facility's Regional Regulatory Compliance Consultant, RRCC on 06/03/25 at 4:03 PM, revealed she had no knowledge of the event regarding R1, she was told about it when she arrived. The RRCC stated as consultants, they can only go by what information is given to them. It could have been a life-or-death situation. The RRCC stated staff need to follow the policy, investigate, and determine why or why not they didn't do what they were supposed to do. The understanding from staff is that R1 was within line of sight, which is why it was not reported. The facility is its own entity, so the facility does not have to consult with consultants when it comes to reporting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, interview and record review, the facility failed to ensure that Resident (R)1 was provided appropriate supervision to prevent 2 separate elopements from the facility on 04/28/25.
On 06/03/25 at 5:53 PM, the Administrator and the Director of Nursing were notified that the failure to ensure that Resident (R)1 was free from two separate elopement incidents from the facility on 04/28/25, constituted Immediate Jeopardy (IJ) at F689.
On 06/03/25 at 5:53 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility that IJ existed as of 04/28/25. The IJ was related to 42 CFR 483.25 - Quality of Care.
On 06/04/25 at 11:54 AM, the facility provided an acceptable IJ Removal Plan. On 06/04/25 at 12:28 PM, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F689 at a lower scope and severity of D.
An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care.
Findings Include:
Review of the facility policy titled Elopement with a complete revision 11/01/2017 states, To safely and timely redirect patients/residents to a safe environment.
Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: restlessness and agitation, Schizophrenia, anxiety disorder, conversion disorder with seizures or convulsions, and moderate intellectual disabilities.
Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/20/25, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicates she was severely cognitively impaired. Further review of the MDS revealed that R1 had no wandering behaviors during the assessment period.
Review of R1's Progress Note dated 04/28/25, revealed, 3:29 PM-Resident was seen going out of door 5 she was immediately followed by staff we did not see her anywhere in the parking lot. I went back in to get more nurses once back outside I saw the resident laying in the middle of the road I called for her to be sure it was her as it was dark and I could not see after getting no response I went in the road and it was [R1] so me and 2 other nurses talked to her and got her to get up and follow us inside where she continued to try to escape so me and a certified nursing assistant (CNA) kept her at the nurses station and when we no longer could do so she got to her room where a CNA sat outside the door to watch her. The DON [Director of Nursing] and unit manager were alerted at the time of the incident.
Review of R1's Progress Note dated 04/28/25 at 7:09 PM, revealed, Resident noted missing after alarm was sounding on unit 2 and staff checked her room. She was noted walking in the staff parking lot on the side of the building heading to the front of the building. After running to catch up with her, she put herself on the ground and started yelling and kicking staff as several assisted her onto a wheelchair (WC), and she slid herself back onto the ground. The Nurse Practitioner (NP) and unit manager notified and per NP order received to transport resident to the ER for evaluation. Resident remained alert, no injuries noted at that time.
Review of the INTERACT Nursing Home to Hospital Transfer Form/Situation Background Assessment Recommendation (SBAR) dated 04/28/25 at 4:43 PM, from Magnolia Manor, unit 2, revealed the reason for the transfer states - Elopement, Combative. Usual functional status- Ambulates independently. Risk alerts- Agitation with risk to harm to self or others, may attempt to exit, and seizures.
Review of Quarterly Nursing - Elopement Risk Observation dated 03/11/25 at 1:10 PM, revealed R1 has a history of wandering, has attempted to leave the health care center, has expressed a desire to leave the health care center, and has a diagnosis that requires supervision.
During an interview with the Nurse Consultant in the presence of the current Administrator on 06/03/25 at 12:09 PM, revealed she is aware of the incident with R1 eloping from the building. The Nurse Consultant stated she heard this from either the Director of Nursing or the previous Administrator, however, she can't recall. The Nurse Consultant stated she was told R1 got out of the building while being in line of sight, R1 then placed herself on the ground, and was able to be re-directed back in the building.
During an interview with the current Administrator on 06/03/25 at 12:11 PM, revealed that he has been in his role since last week, 05/28/25 and was unaware of this event.
During a phone interview with Licensed Practical Nurse (LPN)1 on 06/03/25 at 12:38 PM, revealed she came in at 7:00 AM on 04/28/25, she was getting a report from LPN2 related to R1's elopement that occurred at 1:00 AM, and that R1 went out the back door on unit 2, was found in the street lying on the ground (main road). LPN1 revealed that while getting the report, R1 successfully eloped again around 7:00 AM. The alarms were going off, and another staff member went and checked R1's room; she was not there. Staff started looking for her, and R1 was found in the parking lot within line of sight and was redirected back to the building. LPN1 stated that CNA1 was able to redirect R1 into the building via a non-mechanical wheelchair. LPN1 confirmed that R1 successfully eloped the building twice on 04/28/25.
During an interview with LPN2 on 06/03/25 at 1:04 PM, LPN2 stated on 04/28/25, around midnight, R1 was wandering throughout the building. That night, she exited door 5, which is located in unit 2, which is 4-5 rooms down from her room. The alarm goes off. She and the agency CNA (unable to recall name) split up and looked for her. R1 was not found on the premises, staff came back in the building, got more staff, 2 nurses from stations 3 & 4, and went back out the front door. LPN2 stated she saw a dark shadow on the main road. LPN2 stated she called R1's name out, and she would not respond. LPN2 walked up to the dark shadow and confirmed that it was R1; she was found alert/responsive, and ignoring LPN2. LPN2 stated staff tried talking to her, told her she can't lay in the middle of the road because it's dark and dangerous.
During an interview with the Director of Nursing (DON) on 06/03/25 at 3:35 PM, revealed that she is aware of the incident related to R1. The DON stated she found out from the nurses, LPN2 specifically, and an agency nurse. The DON was told she got out, and staff looked for her and found her laying on the main road. The DON stated she was also told R1 eloped again, right before she arrived at her shift at around 7:00 AM.
On 06/04/25 at 11:54 AM, the facility provided an acceptable IJ Removal Plan, which included the following:
Resident #1 was placed on room supervision after elopement attempt on 4/28/25 at approximately 1am. Room supervision consisted of visual observation of resident's room and supervision was interrupted during change of shift.
Resident #1 was sent to emergency department for evaluation after elopement attempt at 7am. Upon return placed on 1:1 supervision remains on 1:1 supervision. Staff education provided regarding Resident Exit Seeking and Elopement Prevention on 4/30/25.
Elopement Risk evaluations done in the past 90 days on current residents inhouse will be reviewed by Director of Nursing/Designee for accuracy by 6/3/25. Residents identified at risk will be reviewed for appropriate interventions including placement in the Elopement Binder and validated care plans have interventions listed.
The Director of Nursing was reeducated by the Clinical Consultant on 6/3/25 on Accidents and Incidents including:
-elopement process and the elopement binder
-elopement risk assessment process and putting interventions in place based on risks identified.
All Facility Staff will be reeducated by 6/4/25 by the Director of Nursing/Designee on Accidents and Incidents including:
-elopement process and the elopement binder
Licensed Nurses will be reeducated by 6/3/25 by the Director of Nursing on the elopement risk assessment process and putting interventions in place based on risks identified.
Any staff not receiving this education by 6/4/25 will receive prior to working the next scheduled shift. This will be presented in New Hire Orientation.
The Director of Nursing will randomly interview a minimum of 2 staff daily to validate understanding of elopement risk and elopement binder. Interviews will continue for 30 days then 2 staff 3 times per week for an additional 60 days. Results of the audits will be review monthly during QAPI meeting.
The Director of Nursing/Designee will review the facility activity report beginning 6/4/25 in clinical morning meeting to identify documentation and/or elopement risk assessments that may suggest a resident is exit seeking. If identified, the Director of Nursing/Designee will validate interventions are appropriate and care plan is updated.
The Director of Nursing/Designee will review new admission elopement risk assessments in Clinical Morning Meeting beginning 6/4/25 for accuracy and interventions validated if indicated, including placement in the elopement binder and education to staff.
The Medical Director was notified on 6/3/25 of the Immediate Jeopardy.
An Ad Hoc Quality Assurance and Performance Improvement Meeting was held on 6/4/25 to discuss contents of this plan.
Administrator will oversee compliance of this plan.
Allegation of Compliance: 6/4/25

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's policy, record review, and interview, the facility failed to provide documentation to that a proper investigation was conducted regarding an incident that occurred on 04/12/2025 involving an allegation of staff-to-resident abuse concerning Resident (R2).
Findings include:
A review of the facility policy titled Abuse, Neglect, Exploitation, or Mistreatment states: Investigations are prompt, comprehensive, and responsive to the situation and contain founded conclusions. The investigation may include but is not limited to, the following: Identification and removal of the alleged perpetrators. Identification of the alleged victim. Type of alleged abuse. Where and when the incident occurred. Written summaries of interviews with individuals having first-hand knowledge of the incident. NOTE: Employees/witnesses are not to write out statements. Employees/witnesses will be interviewed by designated facility staff, and the interviewer will record all witness accounts in a document, written, dated, and signed by the interviewer. Resolution/outcome. Measures taken to prevent future incidents. All documents pertaining to the investigation must be compiled and stored in the administrator's office.
Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE], with diagnoses including, but not limited to: Cerebral Palsy, adult failure to thrive, cortical blindness, and epilepsy.
Review of R2's Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/14/25, revealed R2's Brief Interview for Mental Status (BIMS) could not be assessed due to R2 never/rarely being understood.
Review of R2's Progress Notes documented by Licensed Practical Nurse (LPN)4 revealed, 04/12/2025 05:56 PM
-Resident alert place in wheelchair. Writer was made aware by staff that resident mother not supposed to be in the resident room visiting with her due to Past history and that the visitation should be supervise by staff. After ADL's writer administer resident Meds., and proceeded to transport resident to the area to visit with her Mother. Writer begun to apologized letting mother know that medication needed to be administer then she started yelling what did you all did to her arm. Writer stated i don't know what happen but I could find out for you. Mother stated in a accusative voice you know exactly what happen. Writer told the mother let me get someone to supervise with you. I took resident away from by her due her aggressiveness, before walking off. Later returning to the nurses station writer was told that mother was contacting the Police.
During an interview with the current Administrator on 06/04/25 at 9:59 AM, in the presence of the Regional Regulatory Compliance Consultant (RRCC) revealed that there is no investigative file found related to R2 and the incident that occurred on 04/12/25. The Administrator stated that all he could locate and provide was the 5-Day Follow-up, and to follow up with the Director of Nursing (DON) since she has been in her role longer. The Administrator stated his expectation is for all reportable files to be investigated thoroughly and for all reportable files to remain in the building for situations like this.
Multiple attempts to interview R2's Resident Representative (RP), which is also her R2's mother, on 06/04/25 at 11:00 AM and 11:22 AM were unsuccessful. The phone number was disconnected and is no longer in service.
Multiple attempts to interview Licensed Practical Nurse (LPN)4 on 06/04/25 at 11:10 AM, 1:05 PM, and 1:18 PM, were unsuccessful. Voicemail box was full and unable to leave a detailed message. An additional attempt was made on 06/05/25 at 10:55 AM, which was unsuccessful.
Multiple attempts to interview R2's Department of Social Services Caseworker, RP/Emergency Contact 2, on 06/04/25 at 11:27 AM and 11:32 AM, was unsuccessful, a detailed message was left for a return call.
During an interview with the DON on 06/04/25 at 10:03 AM, revealed that she is familiar with R2 and the incident that occurred on 04/12/25. The DON stated facility staff are aware that R2's mother is not allowed to visit the resident unsupervised. R2 is overseen by a DSS caseworker due to mistreatment at home prior to admission. R2's mother visited her on 04/12/25 and saw scratches and redness on R2's left upper arm. R2's mother alleged that the scratches and redness on R2's left arm were the result of abuse by a staff member. Law enforcement was notified, and the case ended up being unfounded and closed. There were no witnesses to the alleged event. R2 is care planned for involuntary movements to the UE (Upper Extremity) and has a history of scratching herself. The physician was notified, but there were no changes in medications or treatments. The DON stated that regarding the reportable file, the previous administrator had the reportable file. It is unknown why we can't find it. All reportables were kept in the administrator's office. The DON stated she could not provide any documentation related to the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, record review, and interview, the facility failed to protect Resident (R)1 from misappropriation of more than $600.00 from her personal bank account, for 1 of 1 residents reviewed for misappropriation.
Findings include:
Review of the facility policy with a revision date of 10/23/19, titled, Abuse, Neglect, Exploitation, or Mistreatment documents in the policy, The facility's Leadership prohibits neglect, mental, physical and or verbal abuse . and misappropriation of a resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation . including misappropriation of resident property, and are reported immediately. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.
Review of R1's Facesheet revealed R1 was admitted to the facility on [DATE], with diagnoses that include but not limited to: hypertension, anemia, major depressive disorder and chronic respiratory failure with hypoxia.
Review of R1's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/06/25, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R1 was cognitively intact.
Review of R1's Medical Chart revealed a Progress Note dated 02/24/25 at 4:32 PM, Social Services along with administrator checked in on [R1] to see how she was doing. [R1] stated she's ok, she just don't understand how she can't trust people [R1] was educated on where to keep her funds and who she needs to inform upon her having funds on her persons. [R1] was also educated and offered a lock box that she can have in the event she have funds. [R1] stated, that's ok I keep my money in the bank [R1] stated she will never offer money and she did not read the patient handbook that was given to her.
Review of the facility investigation and Department of Public Health (DPH) 5- Day Follow Up report dated 02/26/25, revealed an allegation of misappropriation. It reported R1 called social services (SS) and stated, I gave a Certified Nurse Assistant (CNA) a check for $12,000.00 on 01/25/2025 to deposit into my bank account. I also told the CNA I was going to bless her with $200.00 for doing this for me. After depositing the check, the CNA told me she was not able to withdrawal the $200.00 due to my account having a negative balance. I told CNA to hold onto my card until she could withdrawal the $200.00 . on 02/27/2025 I checked my bank account and statement and seen where the $200.00 was taken out my banks ATM. I also noticed two other withdrawals on 01/31/2025 of $202.50 each, totaling $405.00. Both of these withdrawals were at the same ATM. I questioned CNA through text messages asking her did she take anymore money and if she needed it all she had to do was ask me for it and I would have given it to her . once I told her that I was going to report her, she stopped responding to me. SS and the Director of Nurses interviewed CNA who admits taking $200.00 from ATM, but denies taking the extra $400.00. In summary of report, facility alleges substantiated abuse of misappropriation of resident property.
Review of R1's Care Plan dated 02/26/25 revealed a problem for Psychosocial Well-Being, [R1] is at risk for negative outcomes of her psychosocial well-being related to alleged misappropriations of her personal funds. The goal recorded R1 will experience no long-term negative outcomes related to their psychosocial well-being through the next assessment period as evidenced by no sustaining negative outcomes such as reduction in socializations, good eating patterns, adequate sleep, and physical signs of anxiety or fear or sadness is not observed.
During an interview on 04/21/25 at 10:50 AM, R1 stated, When I first came here she, (name of alleged perpetrator) cared for me. Then she wasn't here, then she came back. We became really close. The hospital gave me that check. In all, she (CNA1) got more than $600.00 dollars. She was only supposed to get $200.00, I told her that was my blessing to her for depositing the check for me. Then she went and took an additional $400.00, I did not approve that. The facility told me they can't discuss it with me any further, they turned it over to the people they needed to. I'm in charge of everything myself, I have a right to know.
During an interview on 04/21/25 at 3:01 PM, CNA1 confirmed she worked for an agency and was still working. CNA1 stated, [R1] gave me a check to deposit for her, her bank card and the PIN number. It (the check) was for $12,000.00. She didn't want the facility to know she had the check. I deposited it for her at her bank. She told me to withdraw $200.00. I wasn't able to get the money that day. A few days later when I was back to work, on a Saturday, she told me to stop and get the money before I came to work. I went to her banks ATM. I brought her the receipt, the card, and the deposit slip. Somebody else called me from the facility and asked me about it. I work with a staffing agency. An officer never called me and my agency never called me about this and I continue to work, just not there.
During an interview on 04/21/25 at 3:20 PM, the Administrator revealed the CNA was suspended or DNR'd (do not return) here, meaning she cannot return back to this facility. We called the Sheriff's office and reported this to them. A detective came. He said [CNA1] will be charged. When I spoke to the agency, they said they will DNR her. I personally told [R1] the outcome when she asked me. If I have any updates I tell her. I told her the CNA will be charged.
During a follow up interview on 04/21/25 at 3:43 PM, R1 stated she was able to send the facility copies of the transaction from her phone. She pulled up her bank withdrawal transactions of three $200.00 withdrawals, from her February bank statement and the transaction of the deposit of $12,500.00, all dated in January 2025.
During an interview on 04/21/25 at 4:21 PM, the Social Worker (SW) stated R1 told me she received a check, asked the CNA to deposit it for her and she will bless her with $200.00. R1 gave her the bank card. She had to wait to get the $200, for the check to clear. I called CNA1 and she agreed she took the $200.00, but said she did not take additional monies. There were other ATM's at different locations where the money was withdrawn. That CNA was not employed here. I did not call her agency to report this. I do not have a copy of the withdrawal. She pulled it up on her cell phone so I could verify it. The date she reported it to me was 02/21/25. R1 has asked about the outcome. I told her I did not know. I told this to the Mobile DON that was here at the time. R1 said, she is her own responsible party, she does not want her family notified for anything, she will notify them is she wishes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record review, and interview, the facility failed to ensure Resident (R)4 was free of accidents for 1 of 4 residents review for accident hazards.
Findings include:
Review of the facility policy with a revision date of May 5, 2023, titled Fall Management revealed in the policy the definition of a fall, Fall refers to the unintentionally coming to rest on the ground, floor, or other lower level, but not because of an overwhelming external force.
Review of R4's Face Sheet revealed R4 was admitted to the facility on [DATE], with diagnoses that included but was not limited to: pressure ulcer sacrum, hypertensive heart disease with heart failure, dementia, type 2 diabetes mellitus and major depressive disorder.
Review of R4's Annual Minimum Data Set (MDS) with an Assessment Reference Date of 02/27/25, revealed a Brief Interview for Mental (BIMS) score of 13 out of 15, indicating R4 was cognitively intact. Additionally, the MDS revealed R4 required substantial/maximum assistance with bed mobility.
Review of R4's Physician Orders revealed an order dated 01/27/20, for assistance of 2 with bed mobility.
Review of R4's Progress Notes dated 03/04/25 at 7:10 AM, stated, Writer was doing wound care on resident at 6:55 am. When resident was laying over on her right side, she slides out of bed onto the floor. Writer was right there when it happened and tried to slow down her fall to the floor. Writer called Nurse Practitioner (NP). Resident states she is having a little right hip pain. NP was notified about that as well.
Review of R4's Progress Note dated 03/05/25 at 8:11 AM, revealed, Writer called and spoke with resident's nurse at hospital. Resident was admitted with a right femoral fracture. Resident will be undergoing a right total hip replacement today or tomorrow.
Review of R4's Progress Note dated 03/11/25 at 3:35 PM, revealed, Resident returned to facility at 1524 from hospital. Surgical sutures are on the left hip with a bordered gauze covering the area .
Review of Department of Public Health (DPH) Five Day Self Report for R4 recorded under the details of reportable incident, On 03/04/2025 nurse was performing a dressing change. He pulled her toward him and turned her over. Her legs started sliding off the air mattress. Nurse quickly attempted to get to the other side of her bed to stop her from sliding. He attempted to hold her legs up but could not so he lowered her to the floor. He went and got 3 Certified Nurse Assistants (CNA's) to manually lift her to the bed because the batteries for the Hoyer were dead. There was no injury noted at the time. She was sent out to the hospital for x-rays and a fracture of the left femur was found. Intervention prior to reportable incident recorded, Resident was a 2 person assist for bed mobility, Immediate corrective action/assessment following reportable incident recorded, Nurse was disciplined for failure to complete duties as assigned.
Review of a Corrective Action Form dated 03/04/25, revealed Licensed Practical Nurse (LPN)1 was given a verbal warning for a performance behavior. It recorded, Failure to complete duties as assigned. [R4] was a 2 person for bed mobility and employee did not have a 2nd person for treatment change, resulted in resident fall out of bed. Resident resulted with fracture to femur.
During an interview on 04/21/25 at 1:30 PM, LPN1 stated, I was doing patient care, changing a dressing on [R4's] bottom. She was fidgeting with her legs. She was on her left side. She has an air mattress. Her leg was beginning to slide, I put it back. It happened again, both legs. I was holding her legs. I gently lowered her to the ground. I went and got help. At the time I did not know she was a 2 assist with bed mobility.
During an interview on 04/21/25 at 1:59 PM, The administrator stated, He should have had a second person assist. He took accountability for his action.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record review and interviews, the facility failed to provide treatment, consistent with professional standards of practice for Resident (R)11's Pressure Ulcer (PU)/Pressure Injury (PI). Specifically, the facility failed to administer an antibiotic to treat R11's wounds, resulting in a loss of limb.
On 12/19/24 at 10:10 AM, the Administrator was notified that the failure to provide treatment, consistent with professional standards of practice, to a Pressure Ulcer (PU)/Pressure Injury (PI), constituted IJ at F686.
On 12/19/24 at 10:10 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 11/21/24. The IJ was related to 42 CFR 483.25 Quality of Care.
On 12/19/24, the facility provided an acceptable IJ Removal Plan. On 12/19/24, the survey team, validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F686 at a lower scope and severity of D.
An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F686, constituting substandard quality of care.
Findings include:
Review of the facility's policy title, Wound Care Policies and Procedures Reference dated 09/2024, documented, All treatments should be in conjunction with a physician's order . Physician Orders will still be Required for Wound Care .
Review of the facility's policy titled, Medication Management Program, revised 05/05/2023, revealed, The facility implements a Medication Management Program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements. The following scope and rules included: 1.The facility's Medical Director will have an active role in the oversight of medication management, achieved in a variety of ways including medical record reviews, consultation, recommendations from pharmacy consultants and/or recommendations through the Quality Assurance and Performance Improvement process. 2. Licensed Independent Practitioners, licensed nurses, consulting pharmacists, and pharmacy service providers collaborate and review medication orders to ensure medical and clinical necessity and appropriateness. The primary mechanism for this validation is an initial and ongoing medication reconciliation process. 3. Licensed nurses will evaluate, assess, monitor, document and report the effectiveness of the medication regimen that includes all medications and supplements prescribed to treat illness, disease process, or enhance the patient's/resident's quality of life.
Review of R11's Face Sheet revealed R11 was admitted to the facility on [DATE], with diagnoses including but not limited to: Type 2 Diabetes Mellitus with a foot ulcer (Admission), PVD (peripheral vascular disease), Chronic Kidney Disease (CKD), Stage 3b (CMS/HCC) s/p unilateral above knee amputation, pain in left ankle and joints of left foot, acquired absence of right leg above knee.
Review of (R)11's Physician Orders revealed the following: Sodium hypochlorite solution (Dakins apply once daily for 30 days. Use ¼ Dakin's, lightly wet gauze for Wet to Dry (WTD). Do not wet to remove. Remove dry bandage quick like a band aid with necrotic tissue attached. Acetic acid apply once daily for 30 days clean wound with acetic acid. Secondary Tape (retention) apply once daily for 23 days; Gauze roll (stretch) 6 apply once daily for 23 days wrap from beneath toes to mid-calf to attempt to keep resident from being able to remove; Super absorbent gelling fiber pad apply once daily for 9 days.
Review of a VOHRA Wound Physicians Wound Evaluation & Management Summary dated 11/14/24, order revealed dressing treatment plan (Diabetic Wound of Left, Lateral Ankle Full Thickness). Sodium (Na) hypochlorite solution (Dakins) apply once daily for 30 days; Use ¼ Dakins, lightly wet gauze and cover wound with wet gauze for WTD. Do not wet to remove. Remove dry bandage quick like a band-aid with necrotic tissue attached. Acetic acid apply once daily for 30 days clean wound with acetic acid.
Review of a VOHRA Wound Physicians Wound Evaluation & Management Summary dated 11/21/24, revealed the following: Recommendation: Augmentin 875/125 mg Twice a Day (BID) x 14 days. Probiotics Three times a day (TID) x 45 days.
Review of R11's Wound Measurement dated 11/14/24, revealed a wound on her left lateral ankle; left heel:
Wound size [Length (L) x Width (W) x Depth (D)] 2.7 x 4.5 x 0.3
Surface Area 12.15 cm2
Exudate: Moderate Sero-Sanguinous
Thick adherent black necrotic tissue (Eschar) 70%
Slough 10%
Other Viable tissues 20% (SubQ Muscle)
Review of R11's Wound Measurements dated 11/21/24, revealed a diabetic wound of the left heal, full thickness:
Wound Size (L x W x D) 3.0 x 4.4 x 0.3 cm
Surface Area 13.20 cm2
Exudate Moderate Sero-sanguinous
Thick adherent black necrotic tissue (eschar) 70%
Other viable tissue 20%
Review of R11's Medication Administration Record (MAR), did not reveal an order for Augmentin 875/125 mg.
Review of R11's Physician Orders did not reveal an order for Augmentin 875/125 mg BID x 14 days or Probiotics TID x 45 days.
Review of R11's Care Plan with a start date of 06/09/17, documented, At risk for *IMPAIRED SKIN INTEGRITY* Related To (R/T): *Bowel and Bladder incontinence *Assist. with toileting needs *Assist. in bed mobility *Assist with toileting needs *Risk of developing pressure ulcer *Diagnosis (Dx). of PVD *Dx. of Contracture rt hand *Dry skin *Sciatica. Further review of the Care Plan revealed the following approach, [R11] will maintain skin integrity As Evidence By (AEB) no skin breakdown or signs of skin breakdown through target date. Notify Medical Doctor (MD) of any significant changes in skin integrity.
During an interview on 12/18/24 at 11:24 AM, Licensed Practical Nurse (LPN)1 stated, [R11] already had an Above the Knee Amputee (AKA) who developed wounds to her left heel and her left lateral ankle malleolus. Routinely we were keeping the wounds stable. [R11's] interventions included an air mattress and wound boots from the start. After a few weeks we started to see additional break down of those wounds. [R11's] periwounds became inflamed and angry. [R11] had the trifecta of wound healing issues. [R11] had a diagnosis of Diabetes Mellitus (DM), Peripheral Vascular and Arterial Disease so we were working with her aggressively. When we noticed draining of the wounds the MD ordered an antibiotic because she was concerned an underlying infection was starting due to [R11's] high risk comorbidities. On Thursdays every week we round on the residents. I try my best to have her orders and measurements entered into the computer. If I don't, I will try to wrap up on Fridays. I will admit I missed entering the antibiotic order in Matrix (electronic medical record). I feel awful about it. The wound care MD noticed the antibiotic was not entered in Matrix the following week. I totally missed it. The MD was concerned so she sent [R11] out to [local hospital] because the wound looked worse, in lieu of interventions of using the wound boots and air mattress. I have conducted in-services with 4 nurses, unfortunately it has been numerous times when dressings have come off or have not been changed or replaced. When I am off on leave the primary nurses are responsible for wound care. I usually have 15 to 20 plus patients a day for wound changes.
During an interview on 12/18/24 at 12:46 PM, R11's Resident Representative (RR) stated, They called me about her wound. The facility stated they thought it needed to be looked at and they needed more medication to treat her wound. Then I noticed she had a hole in her left leg. Since she has been at that facility, she now has had both legs amputated. Her left leg was amputated on November 22, 2024. We spoke with [local hospital] and they made the decision to remove the left leg on that day or the next day. They ended up going above the knee to amputate. I think they ended up doing the surgery on November 23rd or 24th. The first text I received from [LPN1] was November 21st. [R11] went to the hospital the same day. It was 2 days before that, they called. A telephone number kept coming up, but it came up as spam. The spam number did not leave a message. It was [LPN1] the wound care specialist who told me about the wounds they were treating, and they needed to give her antibiotics. [LPN1] stated they had to send her to the hospital to give the antibiotics since they couldn't administer it there at the facility.
During an interview on 12/18/24 at 1:24 PM, the Interim Director of Nursing (DON) stated, I heard about it. I know [R11] went to the hospital. The wound was healing, but day after day it got worse.
During an interview on 12/18/24 at 2:18 PM, the MD stated, The week before I ordered Augmentin. I entered the note, and I guess it was not entered. I don't know what happened. The next week I assessed [R11] and observed the wound was getting worse. I decided to send her to the hospital. I am subcontracted out for services. We are unable to enter orders into their system. The wound deteriorated and had exudate, so we covered [R11] with a broad-spectrum antibiotic. I think we did a culture on her at that time. The wound deteriorated, I can't say by not receiving the antibiotic what [R11's] outcome would be. I can't answer that question without knowing the updates on her progress.
During an interview on 12/18/24 at 2:50 PM, the Nurse Practitioner (NP) stated, The way the wound doctor functions is she uploads her notes in Matrix and the Wound Nurse is responsible for putting the orders in Matrix. I don't know who the Wound MD is in the facility. The old Wound MD would let me know who they visited, but the new Wound MD doesn't let me know of any interactions between her and the Wound Nurse. The only way I find out about any new orders is reviewing the Wound MD's note that is entered into Matrix. The only thing I did notice was they were not entering orders in Matrix. I informed the old DON of orders not being entered into the system. I have noticed orders being missed on other residents as well.
During an interview on 12/18/24 at 3:09 PM, RR stated, This visit to the hospital prior to Magnolia Manor - [NAME] were to treat her for wounds on her foot. I was notified by the [NP] about the wound. The wound was still not healing, and it turned black. [R11] should have had care before she received wound #2. Wound #2 was open to the bone. The bone was exposed. Something should have been done prior to them sending her to the hospital. She doesn't complain of pain. But [R11] will groan. That is how I know she is in pain. When at the hospital the hospital doctors stated the wound was infected and they needed to remove the leg. We had a conversation prior to this occurring with Magnolia Manor - [NAME] to ensure [R11] established a team to work with her that knows her. So that she can receive consistent care. I had the meeting with the staff that included the head of nursing. The RR was unable to state the others who attended the meeting. RR continued, We established a protocol so we shouldn't have to go through this again after the amputation of the first leg. Now it has happened again. I don't understand why this has happened again. The first wound wasn't doing what it should be doing. If the first wound wasn't healing and clearing up appropriately. Especially since she is diabetic, the second wound should have been aggressively treated so this would not happen again. I found out about wound #2 at the hospital. The last email from the NP was September 23, 2024. They amputated [R11's] leg on November 25, 2024.
During an interview with the Administrator on 12/18/24 at 5:35 PM, the Administrator stated, My expectations going forward is to get an exit interview with the Wound MD every visit. I was not aware this was going on. I will get updated from both the Wound Physician and NP on all interventions. I will look at all reports of treatments and orders and ensure they are carried out as expected.
On 12/19/24, the facility provided an acceptable IJ Removal Plan, which included the following:
Resident #11 no longer resides in the facility.
An audit of notes from the wound physician's current resident list was completed by The Director of Nursing/Designee on 12/19/2024 to identify new physician orders. None identified.
An audit of current wound treatment orders and wound physician notes will be completed on 12/19/2024 by the Director of Nursing/designee to validate wound treatments have been implemented as recommended by wound physician.
An audit of medication administration was completed by the Director of Nursing/Designee on 12/1/2024 for medications and treatments 12/01/2024 through 12/18/2024 to identify missed medications and/or treatments. None Identified.
Licensed nurses were reeducated on Abuse and Neglect, transcribing and following physician orders including notifying responsible party of new orders by the Director of Nursing/Designee on 12/18/2024.
Licensed nurses will receive reeducation on wound care by the Director of Nursing/Designee by 12/19/2024 including:
-Transcribing physician wound treatment orders from wound physician notes
-Providing treatment and care per physician's order
Licensed Nurses not receiving this education by 12/19/2024 will receive prior to their next scheduled shift and this will be completed in New Hire and agency orientation.
Director of Nursing/Designee will review wound physician's notes in clinical morning meeting Monday-Friday beginning 12/20/2024 through 01/10/2025 to validate any recommended orders have been transcribed, implemented, responsible party notified, and care plan updated.
Director of Nursing/Designee will review wound physician's notes in clinical morning meeting Monday-Friday beginning 12/20/2024 through 01/10/2025 to validate updated wound measurements have been documented in the medical record, responsible party notified, and care plan updated.
These weekly audits will be monitored by Administrator and brought for review to the next Quality Assurance and Performance Committee meeting for recommendations and this will continue for 2 additional months.
Ad Hoc QAPI will be held on 12/18/2024.
The Medial Director was notified of the Immediate Jeopardy on 12/18/2024.
Allegation of Compliance Date is 12/19/2024

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and review of facility policy, the facility failed to ensure that medications belonging to Resident (R)15 were properly stored, secured, and/or administered prior to staff leaving the room for 1 of 2 residents reviewed.
Findings include:
Review of the facility policy titled, Pharmacy Services, Policies and Procedures- Section 8: Medication Storage, with a revision date of 04/17/24, documented, 1. Medications and biologicals are stored safely, securely and properly following the manufacturer's recommendations or those of the supplier. In accordance with State and Federal laws, the facility will store all drugs and biologicals in locked compartments under proper temperatures and other appropriate environmental controls to preserve their integrity. 2. The medication and biological supply are only accessible to licensed nursing personnel, pharmacy personnel or authorized staff members.
Review of the facility policy titled, Nursing Policies and Procedures- Medication Management Program with a revision date of 05/05/23, documented, 7. Medications are administered no more than one hour before to one hour after the designated medication pass time. 10. The authorized staff member or licensed nurse must remain with the resident while the medication is swallowed. Never leave medication in a resident room without order to do so.
Review of R15's Face Sheet revealed he was admitted to the facility on [DATE], with diagnoses including, but not limited to: respiratory failure, lymphedema, chronic venous hypertension of right lower extremity, and cirrhosis of liver.
Review of R15's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/01/24 revealed R15 had a Brief Interview of Mental Status (BIMS) score of 15 of 15, indicating that the resident was cognitively intact.
Review of R15's Medication Administration Record (MAR) for December 2024, Physician Orders dated 12/18/24, revealed an administration record for 9:00 AM of Budesonide -formoterol HFA aerosol inhaler; 160/4.5, Coreg 6.25 mg tab, Multi Vite 400-50-500mg capsule, Ferrous Sulfate 325mg tab, Furosemide 40 mg tab, Lactulose solution 10gr/15ml syrup, Lidocaine Adhesive Patch 4%, Mucinex 600mg tab, Protonix 40mg capsule, Potassium Chloride 20 mg capsule, Prostat 30ml syrup, Spironolactone 25mg tab, Ventolin HFA inhaler 90mcg, and Rifaximin 550mg tab. Further review of the MAR revealed Licensed Practical Nurse (LPN)3 signed off for administration on 12/18/24, as a late entry for medications at 10:30 AM.
Review of R15's Physician Orders did not include an order for self-administration of medication.
During an observation on 12/18/24 at 11:00 AM, during the initial tour of R15's room, revealed, two clear medicine cups at the right side of bed on the overbed table. One cup contained multiple-colored pills. The other cup contained a light brown liquid. Both cups were not labeled as to the contents. There were also medications that were in boxes and packages on the overbed table.
During an interview on 12/18/24 at 11:23 AM, Certified Nursing Assistant (CNA)1 revealed that she was aware of the medications on the overbed table for R15. CNA1 stated she noticed the pills at 11:15 AM. CNA1 stated she left the pills there and went to the nurse's station to notify Licensed Practical Nurse (LPN)3, but LPN3 was at lunch. CNA1 further stated she didn't address this issue with anyone else; therefore, the medication remained on the overbed table at bedside as she exited the room.
During an interview on 12/18/24 at 11:29 AM, LPN2 verified the medications on the overbed table in R15's room, LPN2 confirmed the finding of one empty medicine cup, and the other medicine cup with the light brown liquid inside, along with a Lidocaine Patch 700mg, Fluticasone nasal spray and Budesonide 160/4.5mg inhaler. LPN2 stated R15 was not his resident and he had not been in the room today. LPN2 confirmed that LPN3 was the nurse caring for R15, but she was on lunch.
During an interview on 12/18/24 at 1:57 PM, LPN3 confirmed she was the nurse caring for R15. LPN3 stated his BIMS is 15, and he told her to leave the medicine, and she thought he would take it right then. LPN3 stated her normal procedure includes looking at the medication list, checking the medication dosage, pulling medication from the packages, knocking on the door and telling the residents she's coming in to give them their medication. She has the resident's medication ready when she walks in. LPN3 stated that everything she takes in the room with her, she brings back out after usage. LPN3 further stated she was going to double back to R15's room but got sidetracked. LPN3 states R15 always takes his medicine, and most of the time he comes to the cart and takes his medicine. LPN3 stated, I know I shouldn't have left the medications by his bed, but I felt he would have taken his medicine. LPN3 concludes that she understands that medication can not be left at bedside because someone else could have gotten it.
During an interview on 12/19/24 at 9:38 AM, the Interim Director of Nursing (DON) stated that during medication administration she has the MAR in front of her to check the five routes of medication administration. Also, identifying the patient and staying there as long as it takes to ensure the resident takes all medication. The DON revealed the expectation for staff is to follow policy that medication should be administered at bedside and watched. The DON stated she wants to ensure the resident doesn't choke or pocket the medication. She also wants to ensure wanderers don't take the medication. The timeframe for medicine administration is one hour before and one hour after the prescribed order time. The facility does keep some over-the-counter medications at bedside that are labeled with the resident's name on it. The DON also includes if there is a disgruntled resident that doesn't want to take their medicine right then, she advises them that she can't leave the medication unattended in the room and there is a certain amount of time that she has before they are discarded. Late entries are only documented when medications are given late. The DON explains that her expectations are for staff to always follow policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record review, and interviews, the facility failed to protect Resident (R)11 from neglect, by failing to administer (R)11's physician ordered antibiotics, resulting in loss of limb.
On 12/19/24 at 10:10 AM, the Administrator was notified that the failure to administer physician ordered antibiotics as treatment for a Pressure Ulcer (PU)/Pressure Injury (PI), constituted IJ at F600.
On 12/19/24 at 10:10 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 11/21/24. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation.
On 12/19/24, the facility provided an acceptable IJ Removal Plan. On 12/19/24, the survey team, validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F600 at a lower scope and severity of D.
An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F600, constituting substandard quality of care.
Findings include:
Review of the facility's policy titled, Medication Management Program revised on 05/05/23, documented, The facility implements a Medication Management Program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements. The following scope and rules included: 1.The facility's Medical Director will have an active role in the oversight of medication management, achieved in a variety of ways including medical record reviews, consultation, recommendations from pharmacy consultants and/or recommendations through the Quality Assurance and Performance Improvement process. 2. Licensed Independent Practitioners, licensed nurses, consulting pharmacists, and pharmacy service providers collaborate and review medication orders to ensure medical and clinical necessity and appropriateness. The primary mechanism for this validation is an initial and ongoing medication reconciliation process. 3. Licensed nurses will evaluate, assess, monitor, document and report the effectiveness of the medication regimen that includes all medications and supplements prescribed to treat illness, disease process, or enhance the patient's/resident's quality of life.
Review of R11 's Face Sheet revealed R11 was admitted to the facility on [DATE], with diagnoses including but not limited to: Type 2 Diabetes Mellitus with a foot ulcer (Admission), PVD (peripheral vascular disease), Chronic Kidney Disease (CKD), Stage 3b (CMS/HCC) s/p unilateral above knee amputation, pain in left ankle and joints of left foot, acquired absence of right leg above knee.
Review of R11's Wound Measurement dated 11/14/24, revealed a wound on her left lateral ankle; left heel:
Wound size [Length (L) x Width (W) x Depth (D)] 2.7 x 4.5 x 0.3
Surface Area 12.15 cm2
Exudate: Moderate Sero-Sanguinous
Thick adherent black necrotic tissue (Eschar) 70%
Slough 10%
Other Viable tissues 20% (SubQ Muscle)
Review of R11's Wound Measurements dated 11/21/24, revealed a diabetic wound of the left heal, full thickness:
Wound Size (L x W x D) 3.0 x 4.4 x 0.3 cm
Surface Area 13.20 cm2
Exudate Moderate Sero-sanguinous
Thick adherent black necrotic tissue (eschar) 70%
Other viable tissue 20%
Review of a VOHRA Wound Physicians Wound Evaluation & Management Summary dated 11/21/24, revealed, Recommendation: Augmentin 875/125 mg BID x 14 days. Probiotics TID x 45 days.
Review of R11's Medication Administration Record (MAR), did not reveal an order for Augmentin 875/125 mg.
Review of R11's Physician Orders did not reveal an order for Augmentin 875/125 mg BID x 14 days or Probiotics TID x 45 days.
Review of R11's Care Plan with a start date of 06/09/17, documented, At risk for *IMPAIRED SKIN INTEGRITY* Related To (R/T): *Bowel and Bladder incontinence *Assist. with toileting needs *Assist. in bed mobility *Assist with toileting needs *Risk of developing pressure ulcer *Diagnosis (Dx). of PVD *Dx. of Contracture rt hand *Dry skin *Sciatica. Further review of the Care Plan revealed the following approach, [R11] will maintain skin integrity As Evidence By (AEB) no skin breakdown or signs of skin breakdown through target date. Notify Medical Doctor (MD) of any significant changes in skin integrity.
During an interview on 12/18/24 at 11:24 AM, Licensed Practical Nurse (LPN)1 stated, [R11] already had an Above the Knee Amputee (AKA) who developed wounds to her left heel and her left lateral ankle malleolus. Routinely we were keeping ithe wounds stable. [R11's] interventions included an air mattress and wound boots from the start. After a few weeks we started to see additional break down of those wounds. [R11's] periwounds became inflamed and angry. [R11] had the trifecta of wound healing issues. [R11] had a diagnosis of Diabetes Mellitus (DM), Peripheral Vascular and Arterial Disease so we were working with her aggressively. When we noticed draining of the wounds the MD ordered an antibiotic because she was concerned an underlying infection was starting due to [R11's] high risk comorbidities. On Thursdays every week we round on the residents. I try my best to have her orders and measurements entered into the computer. If I don't, I will try to wrap up on Fridays. I will admit I missed entering the antibiotic order in Matrix (electronic medical record). I feel awful about it. The wound care MD noticed the antibiotic was not entered in Matrix the following week. I totally missed it. The MD was concerned so she sent [R11] out to [local hospital] because the wound looked worse, in lieu of interventions of using the wound boots and air mattress. I have conducted in-services with 4 nurses, unfortunately it has been numerous times when dressings have come off or have not been changed or replaced. When I am off on leave the primary nurses are responsible for wound care. I usually have 15 to 20 plus patients a day for wound changes.
During an interview on 12/18/24 at 12:46 PM, R11's Resident Representative (RR) stated, They called me about her wound. The facility stated they thought it needed to be looked at and they needed more medication to treat her wound. Then I noticed she had a hole in her left leg. Since she has been at that facility, she now has had both legs amputated. Her left leg was amputated on November 22, 2024. We spoke with [local hospital] and they made the decision to remove the left leg on that day or the next day. They ended up going above the knee to amputate. I think they ended up doing the surgery on November 23rd or 24th. The first text I received from [LPN1] was November 21st. [R11] went to the hospital the same day. It was 2 days before that, they called. A telephone number kept coming up, but it came up as spam. The spam number did not leave a message. It was [LPN1] the wound care specialist who told me about the wounds they were treating, and they needed to give her antibiotics. [LPN1] stated they had to send her to the hospital to give the antibiotics since they couldn't administer it there at the facility.
During an interview on 12/18/24 at 1:24 PM, the Interim Director of Nursing (DON) stated, I heard about it. I know [R11] went to the hospital. The wound was healing, but day after day it got worse.
During an interview on 12/18/24 at 2:18 PM, the MD stated, The week before I ordered Augmentin. I entered the note, and I guess it was not entered. I don't know what happened. The next week I assessed [R11] and observed the wound was getting worse. I decided to send her to the hospital. I am subcontracted out for services. We are unable to enter orders into their system. The wound deteriorated and had exudate, so we covered [R11] with a broad-spectrum antibiotic. I think we did a culture on her at that time. The wound deteriorated, I can't say by not receiving the antibiotic what [R11's] outcome would be. I can't answer that question without knowing the updates on her progress.
During an interview on 12/18/24 at 2:50 PM, the Nurse Practitioner (NP) stated, The way the wound doctor functions is she uploads her notes in Matrix and the Wound Nurse is responsible for putting the orders in Matrix. I don't know who the Wound MD is in the facility. The old Wound MD would let me know who they vistited, but the new Wound MD doesn't let me know of any interactions between her and the Wound Nurse. The only way I find out about any new orders is reviewing the Wound MD's note that is entered into Matrix. The only thing I did notice was they were not entering orders in Matrix. I informed the old DON of orders not being entered into the system. I have noticed orders being missed on other residents as well.
During an interview on 12/18/24 at 3:09 PM, RR stated, This visit to the hospital prior to Magnolia Manor - [NAME] were to treat her for wounds on her foot. I was notified by the [NP] about the wound. The wound was still not healing, and it turned black. [R11] should have had care before she received wound #2. Wound #2 was open to the bone. The bone was exposed. Something should have been done prior to them sending her to the hospital. She doesn't complain of pain. But [R11] will groan. That is how I know she is in pain. When at the hospital the hospital doctors stated the wound was infected and they needed to remove the leg. We had a conversation prior to this occurring with Magnolia Manor - [NAME] to ensure [R11] established a team to work with her that knows her. So that she can receive consistent care. I had the meeting with the staff that included the head of nursing. The RR was unable to state the others who attended the meeting. RR continued, We established a protocol so we shouldn't have to go through this again after the amputation of the first leg. Now it has happened again. I don't understand why this has happened again. The first wound wasn't doing what it should be doing. If the first wound wasn't healing and clearing up appropriately. Especially since she is diabetic, the second wound should have been aggressively treated so this would not happen again. I found out about wound #2 at the hospital. The last email from the NP was September 23, 2024. They amputated [R11's] leg on November 25, 2024.
During an interview with the Administrator on 12/18/24 at 5:35 PM, the Administrator stated, My expectations going forward is to get an exit interview with the Wound MD every visit. I was not aware this was going on. I will get updated from both the Wound Physician and NP on all interventions. I will look at all reports of treatments and orders and ensure they are carried out as expected.
On 12/19/24, the facility provided an acceptable IJ Removal Plan, which included:
Resident #11 no longer resides in the facility.
An audit of notes from the wound physician's current resident list was completed by The Director of Nursing/Designee on 12/18/2024 to identify new physician orders. None identified.
An audit of medication administration was completed by the Director of Nursing/Designee on 12/18/2024 for medications and treatments 12/01/2024 through 12/18/2024 to identify missed medications and/or treatments. None identified.
Licensed nurses were reeducated on Abuse and Neglect, transcribing and following physician orders including notifying responsible party of new orders by the Director of Nursing/Designee on 12/18/2024.
Licensed Nurses not receiving this education by 12/19/2024 will receive prior to their next scheduled shift and this will be completed in New Hire and agency orientation.
Director of Nursing/Designee will review wound physician's notes in clinical morning meeting Monday - Friday beginning 12/20/2024 until 01/10/2025 to validate recommend orders have been transcribed, implemented, responsible party notified, and care plan updated.
Director of Nursing/Designee will review wound physician's notes in clinical morning meeting Monday - Friday beginning 12/20/2024 until 01/10/2025 to validate updated wound measurements have been documented in the medical record, responsible party notified and care plan updated.
These weekly audits will be monitored by the Administrator and brought for review to the next Quality Assurance and Performance Committee meeting for recommendations and this will continue for 2 additional months.
Ad Hoc QAPI will be held on 12/19/2024.
The Medical Director was notified of the Immediate Jeopardy on 12/19/2024.
Allegation of Compliance Date is 12/19/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, the facility failed to ensure that Resident (R)2 was free from physical abuse by Licensed Practical Nurse (LPN)2, for 1 of 19 residents reviewed for abuse.
Findings include:
Review of the facility policy titled Leadership Policies and Procedures Organizational Ethics Abuse, Neglect, Exploitation, or Mistreatment last revised on 10/23/19, documented, the facility's leadership prohibits neglect, mental, physical, and or verbal abuse, use of a physical of chemical restraint not required to treat medical condition, involuntary seclusion, corporal punishment and misappropriation of a patient/resident property and/or funds and ensures violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or mental anguish. Abuse also includes the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Willful as used in the individual means the individual must have acted deliberately, not that individual must have intended to inflict injury or harm. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.
Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE], with diagnoses including but not limited to: dementia with moderate anxiety, major depressive disorder, generalized anxiety disorder and, dysphasia.
Review of R2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 11/01/24, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 99, which indicates that R2 was not cognitively intact and was unable to complete the interview.
Review of a Witness Statement written by LPN1, dated 10/31/24, documented, I [LPN2] was sitting at the nurses station on Unit 1 at 6:35 AM. The resident (R2) came up to the nurses station asking the third shift nurse (LPN2) for a 'puff' of her inhaler several times. [LPN2] kept ignoring [R2] at first but later began to argue with the resident about the inhaler. [R2] became upset and said that she was going to call 911. The resident then proceeded to walk around to the phone and lifted it up and started dialing the number. [LPN2] then tried to snatch the telephone from the resident, and they began tussling with the phone. I asked [LPN2] to let the resident have the phone, once [LPN2] let go of the telephone the resident reared back with the phone and hit [LPN2] hard in the face with the telephone. [LPN2] then snatched the telephone back from the resident and hit her gently in the face. [LPN2] then went around the nurses stations towards the resident and the resident turned and walked towards me [LPN1]. I then stepped between both of them, the resident winked at this nurse [LPN1], then closed her eyes and slid to the floor. After assisting the resident back up, this nurse escorted the resident back to her room and called to notify the Director of Nursing (DON).
Review of a Witness Statement written by LPN2, dated 10/31/24, documented, At 6:45 AM the resident came up to the nurses station for an inhaler. I let the resident [R2] know that she did not have an inhaler until later in the day. Resident then went around to the phone and picked up the phone and I touched the cord. When I did, [R2] hit me hard in the face. She then went around to [LPN1] and when I walked to her she said oh and fell in my arms. I placed the resident on the floor for a few minutes and then [LPN1] ambulated her back to her room.
Review of a Conclusion Summary dated 10/31/24, documented, At 6:45 AM [LPN1] employed by the facility witnessed [LPN2], an agency LPN strike a resident in the face with a telephone. The altercation occurred because the resident had asked to be given an inhaler, which was prescribed for her to given PRN (as needed). The nurse responded to the resident, you don't have one and the resident proceeded to pick up the phone to call 911. [R2] and [LPN2] tussled with the phone and the nurse was able to grab the phone from the resident. Resident then walked away from the desk and proceeded to use another phone on the hall and [LPN2] attempted to take that phone away from [R2] as well. Aggravated, [R2] hit [LPN2] in the face with the phone and [LPN2] hit the resident back in the face with the phone. Eyewitness who was present immediately called the DON to report this incident and escorted the resident to her room and remained with her until the other nurse had left the unit as that nurse had instructed her to do. After administrative investigation concluded it revealed that the allegation of physical abuse is substantiated.
During an interview on 11/19/24 at 3:10 PM, LPN1 revealed that they witnessed LPN2 hit R2 while at the nurses station on Unit 1. R2 came to the nurses station to ask for her PRN (as needed) inhaler and requested her nurse for the day, R2 requested the inhaler from LPN2 several times. LPN2 refused to give R2 her inhaler and stated that she did not have a Physician Order for an inhaler but made no attempts to look at R2's medical record or in the medication/treatment carts. LPN2 and R2 began to argue with each other, then R2 attempted to call 911 with the phone at the nurses station. LPN2 refused to allow R2 to use the phone and the two started tugging back and forth with the phone then I (LPN1) intervened by trying to deescalate the situation by telling LPN2 to let go of the phone. LPN1 stated eventually LPN2 let go of the phone and R2 hit LPN2 hard in the face with the phone, LPN2 retaliated and hit R2 back in the face with phone (but not as hard). LPN1 further stated, she got between the resident and LPN2 to stop them from fighting anymore. R2 then slid herself to the ground (purposely), I had to find someone to help me assist the resident up from the floor. After finding help with assisting the resident back into her wheelchair, I assisted the resident to her room and instructed her to stay there for a while because I didn't want R2 and LPN2 to cross paths again. I then went outside to notify the Director of Nursing (DON) of the situation. LPN1 further stated, R2 did not have any injuries due to the incident and LPN2 was not allowed to return back to the facility as an agency nurse. LPN1 stated that LPN2 previously worked at the facility as a staff nurse but was eventually terminated due to behavioral issues/customer service. LPN1 stated that LPN2 often had anger issues but mostly with tone/verbally. LPN1 stated that she never witnessed LPN2 be physically abusive to a resident in the past but has overheard LPN2 be rude to residents/other staff members.
An attempted interview on 11/19/24 at 3:50 PM, with R2 was unsuccessful due to her cognitive status, a phone call was made to her Resident Representative and a message was left with contact information.
An attempted interview with LPN2 on 11/20/24 at 11:06 AM, was unsuccessful, a voicemail message was left with callback information.
During a phone interview on 11/20/24 at 12:12 PM, with the Agency Staffing Coordinator revealed that they were not allowed to disclose any information at this time related to LPN2's employment status. The Agency Staffing Coordinator stated that the Administrator of Staffing Agency will call back when they return in the office and provided call back information. A call back was never received from the Agency Staffing company.
A second attempt on 11/20/24 at 12:30 PM, was made to LPN2 but was unsuccessful.
A third attempt on 11/20/24 at 12:46 PM, LPN2 stated that they are not at liberty to speak with the state agency related to this matter at this time and provided information to their lawyer.
During an interview on 11/20/24 at 4:48 PM, the Assistant Director of Nursing (DON) revealed that the abuse allegation was substantiated and LPN2 was put on a do not return list. The DON stated they were notified around 7 that morning that LPN1 witnessed LPN2 hit R2. When they arrived to the facility, R2 was in her room and they assessed the resident and found no injury. LPN2 was at the nurses station completing medication count with another nurse so they could exit the facility. I notified the resident representative along with the medical director and law enforcement. Law enforcement was able to interview the resident and LPN1 and both confirmed that LPN2 hit R2 with a phone. The last updates that I have for the incident was that law enforcement was pursing LPN2, and she should have a court date soon.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility policy, the facility failed to maintain an effective pest control program to remain free of pests/rodents, in 1 of 4 units.
Findings include:
Review of the facility policy revised on June 20, 2023, titled Pest Control states, Facility will maintain an effective pest control program to prevent or eliminate infestation of pests and rodents.
1. Contracted pest elimination service will provide monthly service for the most common pests such as rodents, cockroaches and other crawling invaders. This includes a sanitation and structural inspection to identify any issues conducive to pest activity and proactive monitoring. 5. Proper sanitation will be maintained, and clutter reduced to prevent food and harborage for pests.
During an observation 09/24/2024 at 10:31 AM, a roach like insect was observed on a CPAP machine.
During an observation on 09/24/2024 at 10:35 AM, a dead spider was observed on the window seal in room [ROOM NUMBER].
During an observation on 09/24/2024 at 10:42 AM, a nurse was walking around the nurses' desk and hit the water machine, which resulted in multiple roach like insects scatter. Additionally, a roach like insect was observed in the bathroom and a waterbug like insect was turned over dead at the nurses' station on the 200 Hall.
Review the Pest Control Logs on 09/24/2024 at 3:50 PM, revealed all pest control activity logs compared to Ecolab service areas revealed no activity was found.
During an interview on 09/24/2024 at 10:15 AM, Resident (R)1 stated, It was six roaches in my CPAP machine. This place is infested with roaches.
During an interview on 09/24/2024 at 10:25 AM, Housekeeper 2 stated, I see roaches in certain rooms. We use bleach cleaner spray and shackle spray.
During an interview on 09/24/2024 at 10:44 AM, Certified Nursing Assistant (CNA)1 stated, I am prn [as needed] mostly on first shift. I see roaches them everywhere. I have only seen pest control once. They were at the nursing station. I see them throughout the day. Next door when I came in today the room [ROOM NUMBER], they [roaches] were running everywhere.
During an interview on 09/24/2024 at 10:40 AM, Licensed Practical Nurse (LPN)1 stated, The roaches are everywhere.
During an interview on 09/24/2024 at 10:46 AM, Housekeeper 1 stated If we see a bug we talk to maintenance to come spray. They tell us afterwards so after they spray we can come in and clean behind them. We do try our best to clean up immediately. I informed the staff to let me know immediately. We have logs to record at each nurses' station to document the date time, location and type of pests they have seen. Everyone is responsible for reporting. My team is willing to do whatever. We have isolated rooms where we have sprayed and then return them to their rooms.
During an interview on 09/24/2024 at 10:59 AM, the Administrator stated, I just was made aware of the problem today. I have called maintenance.
During an interview on 09/24/2024 at 11:36 AM, the Administrator stated, We are getting her a new CPAP machine, it should be here within an hour.
During an interview on 09/24/2024 at 11:07 AM, Maintenance 1 stated, The biggest issue is their (residents) nightstand is stored with food in it. First thing is they need to have that clean and then we can treat their rooms. If I don't know about it I can't fix the problem. We have a maintenance log at each nursing station. I reviewed Pest Control Log for Unit 200. Ecolab guy should come out this week. They come out monthly. If additional visits are needed especially roach treatment they will come out at no additional charge.
During an interview on 09/24/2024 at 3:47 PM, Maintenance 1 compared the log to service in the areas that were spray over the three months. Maintenance 1 stated, EcoLab comes in and review the logs and will spray the rooms with activity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and facility policy review, the facility failed to provide proper safety protocols for 5 out of 5 residents who smoke/vape, Residents (R)1, R2, R3, R4, and R5. Additionally, the facility failed to conduct smoking assessments for 2 out of 5 residents who smoke/vape, R4 and R5. Specifically, residents were smoking vapes in the facility and sharing vapes with other residents.
On 04/30/2024 at 09:34 AM, the Administrator was notified that the failure to conduct assessments on residents who smoke/vape and failing to provide proper safety protocols for residents who smoke/vape constituted Immediate Jeopardy (IJ) at F689.
On 04/30/2024 at 09:34 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 04/30/2024. The IJ was related to 42 CFR 483.25 - Quality of Care.
On 04/30/2024 at 2:30 PM, the facility provided an acceptable IJ Removal Plan. On 05/01/2024 at 02:30 PM, the survey team validated the facility's corrective actions and removed the IJ, as of 05/01/2024. The facility remained out of compliance at F689 at a lower scope and severity of E.
An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care.
Findings include:
Review of the facility's policy titled, Smoking Regulation, dated 11/1/2017, revealed, It is highly encouraged that the Facility retains a smoke free environment. If the Facility chooses not to retain a smoke-free environment (Smoking Facility), the Facility's Leadership will establish an appropriate and safe environment for smoking in the Facility to reduce risks to patients/residents who smoke, reduce risks of passive smoking for others, and reduce the risk of fire. The procedures included: 1. Staff is prohibited from smoking on facility's property except for those areas specifically designated for smoking. 2. If the Facility provides long-term care and is a Smoking Facility, a policy is established by the Leadership that permits patients/residents to smoke without written authorization from a licensed independent practitioner. This policy designates locations that are environmentally separate from all patient/resident care areas. 3. The Smoking Facility's Leadership will institute a smoking policy for patients/residents, that: A. Establishes where smoking can occur on facility property. B. Minimizes the smoke to the greatest extent possible. C. Discourages all such smoking. D. Provides education and options for smoking cessation activities. 4. The Smoking Facility's staff will complete the Safety Evaluation for Smoking Care Plan form (Assessment) for the patient's/resident's need for adaptive equipment upon admission, quarterly, and annually. When completed, the record is filed in the patient's/resident's medical record. 6. Patients/Residents will not smoke without direct supervision. This facility is a smoke-free environment. There are no designated smoking areas inside the building. Residents wishing to smoke during their stay will be permitted to do so only with staff supervision and only in designated areas. Smoking is strictly prohibited in any other areas of the facility and/or its property, without exception. Residents must utilize protective gear/apparatus (flame retardant smoking aprons, gloves, etc.) provided for in their safety evaluation and/or care plan, if applicable. Tobacco products are limited to tobacco and/or clove cigarettes, cigars and/or pipes.
Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with a diagnosis including but not limited to, calculus of kidney due to nephrostomy catheter.
R1's MDS Quarterly Review dated 02/08/2024 revealed R1 has a Brief Interview of Mental Status (BIMS) score of 15, indicating they are cognitively intact.
Review of R1's smoking assessment revealed, Smoking materials: disposable vape observation dated 03/21/2024. Frequency of use: less than daily. Smokes in unauthorized areas: Minimal Problem. Mobility: Minimal Problem
Review of R1's Electronic Medical Record (EMR) did not reveal documentation that R1 was assessed for acknowledgement of smoking policy.
Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE] with a diagnosis including but not limited to, hypoxemia.
Review of R2's Quarterly MDS dated [DATE] revealed R2's BIMS score was 15.
Review of R3's Face Sheet revealed R3 was admitted to the facility on [DATE] with diagnoses including but not limited to, paraplegia and chronic obstructive pulmonary disease (copd).
Review of R3's Quarterly MDS dated [DATE] revealed R3's BIMS score was 15.
Review of R4's Face Sheet revealed R4 was admitted to the facility on [DATE] with a diagnosis including but not limited to, seasonal allergic rhinitis.
Review of R4's Quarterly MDS dated [DATE] revealed R4's BIMS was 15.
Review of R4's EMR did not reveal documentation that R4 was assessed for smoking/vaping.
Review of R5's Face Sheet revealed R4 was admitted to the facility on [DATE] with diagnoses including but not limited to: nondisplaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, copd, and tobacco use.
Review of R5's Quarterly MDS dated [DATE] revealed R5's BIMS score was 15.
Review of R5's EMR, did not reveal documentation that R5 was assessed for smoking/vaping.
During an interview on 04/29/24 at 1:48 PM, License Practical Nurse (LPN)1 stated to the surveyor, I just caught [R1] vaping in the room. He is keeping it in his gown.
During an interview on 04/29/24 at 1:51 PM, R1 admitted to vaping in his room.
During an interview on 04/29/24 at 3:05 PM, R1 stated, I gave the vape back to my roommate. We share the vape, it's not mine, it is his.
During an interview on 04/29/24 at 3:11 PM, the Assistant Director of Nursing (ADON) stated, We have talked to the family members about supplying those (vapes) to the resident. We have educated the family members.
During an observation and interview on 04/29/24 at 3:12 PM, R2 was vaping in the courtyard area of the facility and was unsupervised. When asked if he shares his vape with his roommate, R2 responded, I don't know what you are talking about. When asked does he vape in the room R2 responded, I don't know what you are talking about.
During an interview on 04/29/24 at 4:53 PM, LPN2 stated, When I first came here to work it was a smoking facility. Then it was a non-smoking facility. Now, I am unsure. But yes, we have a problem with residents vaping.
During an interview on 04/30/24 at 9:34 AM, the Administrator stated, We are a smoke free facility. We do not have a vaping policy. When we see or discover they are vaping, we confiscate the vape. They have noted they mail order them in the facility, they have them delivered with outside food via uber. We have educated the families not to bring in vapes for the residents.
During an interview on 04/30/24 at 12:30 PM, R3 stated, A nurse told me I could smoke in the bathroom, but she was suspended for 2 to 3 days. Now we can only vape in the courtyard. I keep my vape in my drawer or locked in my bag, so it won't get stolen. The staff allow us to keep it on us.
During an interview on 4/30/24 at 12:40 PM, the Administrator stated, On admission, they sign the no smoking document.
During an interview on 04/30/24 at 12:56 PM, Registered Nurse (RN)1 stated, [R3] vapes, I am unsure how she gets her vapes, that is a mystery. The residents are good with the rules as far as I know. I am usure of a policy pertaining to vaping.
During an interview on 04/30/24 at 2:06 PM, R4 stated, I vape. I just came from outside using my vape. I keep it locked in my book bag. I usually order it, and it comes in the mail. We are only allowed to vape in the courtyard.
During an interview on 04/30/24 at 2:00 PM, R5 revealed that she smokes and has been for a long time. R5 stated that the facility does not allow people to smoke, so she started vaping instead. R5 further stated that she typically goes to the back yard to vape because it's easier to hide. Both she and her roommate vape in the facility. R5 continued, her roommate does vape in the room and conceals the vapors by blowing the smoke down her shirt. R5 revealed that someone who works in the facility buys her and her roommate vapes. R5 stated, I do not want to say her name because she might get fired. R5 revealed that the staff member was a nurse, but would not specify their name or give a description. R5 concluded that once she gets money in her account, she will typically give the nurse some money to buy vapes for her and her roommate and that they take turns buying vapes from the same nurse, this has been going on for a while now.
During an interview on 04/30/24 at 4:00 PM, the Director of Nursing (DON) stated, We checked the smoking assessments, I was not aware of [R4] and [R5] vaping. We do not have smoking assessment for those residents.
The facility's accepted removal plan revealed:
Magnolia Manor [NAME] Plan of Removal F689_ 4/30/2024
Residents #1, #2, #3, #4, #5 smoking assessments were completed on 04/30/2024.
Residents #1, #2, #3, #4, and #5 turned in their smoking material to the nurse for secure storage on 04/30/2024.
The Administrator reviewed with the identified residents the smoking policy including:
-All residents are prohibited from keeping any type of smoking materials, including electronic cigarette vapes in their rooms or on their person. These materials must be turned into a nurse for secured storage.
-Residents may only smoke/vape in designated areas that have been approved and identified as a designated smoking area.
-Residents will be supervised by facility staff while smoking/vaping during the entirety of the time.
-Assigned facility staff will accompany residents wishing to smoke/vape to the designated smoking area at the times outlined in the smoking schedule.
-No other person, including but not limited to residents, families and visitors may directly provide smoking materials including vapes to any resident.
-Designated staff members, Social Services and Activity staff, may purchase, using the resident's personal funds, smoking material/vapes for residents allowed to smoke as requested. Facility will keep a log for each resident on what is purchased and kept in the secured area. Receipts will be kept for record keeping and reconciliation.
Residents currently residing in the facility were asked by facility leadership if they currently use vapes or are smokers on 04/30/2024.
An additional 11 residents identified as smokers/vapers.
Those 11 self-identified as smokers, including the use of vapes will have a smoking acuity (assessments) completed by a licensed nurse on 04/30/2024 to determine any additional supervision the resident may require when smoking /vaping.
The Administrator will review on 04/30/2024 with the residents, that have self-identified as smoker/vapers, and Facility Staff the smoking guidelines policy including:
-All residents are prohibited from keeping any type of smoking materials, including electronic cigarette vapes in their rooms or on their person. These materials must be turned into a nurse for secured storage.
-Residents may only smoke/vape in designated areas that have been approved and identified as designated smoking area.
-Residents will be supervised by facility staff while smoking/vaping during the entirety of the time.
-Assigned facility staff will accompany residents wishing to smoke/vape to the designated smoking area at the times outlined in the smoking schedule.
-No other person, including but not limited to residents, families and visitors may directly provide smoking materials including vapes to any resident.
-Designated staff members, social Services and Activity staff, may purchase from the resident's personal funds, smoking material/vapes for residents allowed to smoke as requested. Facility will keep a log for each resident on what is purchased and kept in the secured area. Receipts will be kept for record keeping and reconciliation.
Residents who had smoking materials have turned in those smoking materials to the nurse for storage in a secured area on 04/30/2024.
Smoking Cessation products will be offered to any resident that has identified as a smoker. If they chose to utilize smoking cessation products, the physician will be notified and orders obtained on 04/30/2024.
Any staff not receiving this smoking guidelines policy education on 05/01/2024 will receive prior to working the next scheduled shift. This will be presented in New Hire Orientation and for agency staff.
The Director of Nursing will validate in clinical meeting Monday- Friday that Smoking Acuity (Assessment) has been completed for newly admitted residents identifying as a smoker/vaper.
The Director of Nursing will randomly interview a minimum of 2 staff and 2 interviewable residents weekly times 4 weeks then monthly for 2 additional months to validate understanding and compliance with the smoking guidelines.
Administrator/designee will round in resident rooms 2 times per day for 5 days, then daily for 3 additional weeks then monthly for 2 additional months to validate there are no smoking materials in residents' rooms or on their persons.
Any concerns will be addressed at time of discovery.
The Medical Director was notified on 04/30/2024 of the Immediate Jeopardy.
Ad Hoc Quality Assurance Performance Improvement Meeting was held on 04/30/2024 to discuss contents of this plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a homelike environment by providing adequate linens.
Findings include:
Review of the facility's policy titled, Maintenance/Housekeeping Policies and Procedures: Subject: Laundry with an effective date of 03/2006, revealed, Availability of Linens: 1. Sufficient clean linen is available at all times in the proper quantity to meet the demands of the facility. 2. Access to clean linens is maintained during all shifts every day. 4. A plan is devised and documented to address situations in which there is inadequate laundry available, or in instances when the facility or the vendor are unable to meet the requirements of decontaminating soiled laundry or providing clean laundry
Review Resident (R)130's Face Sheet revealed she was admitted to the facility on [DATE] with diagnosis including, but not limited to, difficulty in walking, muscle wasting and atrophy, anxiety disorder, and major depressive disorder.
Review of R130's Quarterly Minimum Data Set (MDS) with an Annual Reference Date (ARD) of 12/10/23 revealed she has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating she is cognitively intact.
During an observation on 02/20/24 at 12:18 PM revealed R130 lying in her bed with no fitted sheet on her mattress.
Review of R201's Face Sheet revealed she was admitted to the facility on [DATE] with diagnosis including, but not limited to, dementia, Cognitive communication deficit, Urinary tract infection, Vascular dementia, Difficulty in walking, Need for assistance with personal care, chronic pain, anxiety disorder, and repeated falls.
Review of R201's Quarterly MDS with an ARD of 01/10/24 revealed she has a BIMS of 5 out of 15, indicating she has severe cognitive impairment.
During an observation on 02/20/24 at 12:45 PM revealed R201 sitting in her wheelchair, but she did not have any linen on her mattress for her bed.
During an interview on 2/22/24 at 10:48 AM with the Activities Director (AD) revealed In January they had a lot of laundry missing and they would have to go to rooms to find linen. CNA's were taking the linen to use for their particular residents and hiding in certain places in resident's rooms. They completed a linen sweep each day.
During an interview with the Social Services Assistant (SSA) revealed the linen was an issue because they were transitioning between laundry companies, and everything had to be done in house. They did a linen sweep each day to collect all linen and make sure that something was on their bed, even if it wasn't a fitted sheet.
During an interview on 02/22/24 at 1:10 PM with the Social Services Director (SSD) revealed the facility did not have enough linen for everyone a few weeks ago and if they didn't have fitted sheets they would use flat sheets to cover the mattresses.
Review of R116's face sheet revealed R116 was admitted on [DATE], with diagnoses including but not limited to; dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, anxiety disorder, muscle weakness (generalized) and other reduced mobility.
Review of the Quarterly MDS with an ARD of 01/17/24, revealed R116 has a BIMS score of 99, which indicates the resident was unable to complete the interview.
During an observation of R116 on 02/ 20/24 AT 11:12 P.M., R116, the linen sheets were not clean and contained several dirt spots.
Review of R55's face sheet revealed R55 was admitted on [DATE], with diagnoses, including but not limited to, dementia without behavioral disturbance, psychotic disturbance, anxiety, Parkinsonism, altered mental status, repeated falls, unsteadiness on feet, muscle wasting and atrophy, lack of coordination, and limitation of activities due to disability.
Review of the annual MDS with an ARD of 2/14/24 revealed R55 has a BIMS score of 7 out of 15, which indicates severe cognitive impairment.
During an observation of R55 on 02/20/24 at 11:16 A.M., linens were not present on the mattress.
Review of R6 face sheet revealed R6 was 02/25/07, with diagnoses including but not limited to dementia.
Review of the Annual MDS with an ARD of 01/17/24, revealed R6 has a BIMS score of 99, which indicates the resident was unable to complete the interview.
During an observation of R6 on 02/ 20/24 at 11:32 A.M., sheets were not present on the bed and dirty particles were on the mattress.
Review of R88's face sheets revealed R88 was admitted [DATE], with diagnoses including but not limited to adult failure to thrive, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and pain.
Review of the Quarterly MDS with an ARD of 12/11/23 has a BIMS score of 99, which indicates the resident was unable to complete the interview.
During an observation of R88 on 02/20/24 at 12:14 P.M., sheets were not present on the bed.
Review of R77's face sheet, revealed that she was admitted to the facility on [DATE], with a diagnosis including, but not limited to, major depressive disorder, repeated falls, need for assistance with personal care, limitation of activities, anxiety disorder, and type 2 diabetes mellitus.
Review of the Quarterly MDS with an ARD of 1/19/24, revealed that she has a BIMS score of 15 out of 15, indicating she is cognitively intact.
During an observation on 02/22/24 at 11:25 AM, R77 did not have any bed sheets, and was laying on a bare mattress.
During an interview on 02/22/24 at 12:00 PM, CNA7 revealed that the facility did not have any clean linen at this time.
Review of R59's Face Sheet revealed R59 was admitted to the facility on [DATE] with diagnoses including but not limited to: acute respiratory failure unspecified with hypoxia, chronic pain syndrome, other lack of coordination, generalized muscle weakness, morbid (severe) obesity due to excess calories, and need for assistance with personal care.
Review of R59's Quarterly MDS with an ARD date of 02/15/2024 revealed a BIMS score of 15 out of 15, indicating R59 was cognitively intact.
During an observation on 02/20/2024 at 12:04 PM the resident linens were observed with a stain to the top/flat sheet. A brown ring was observed on the fitted sheet and bowel movement (BM) stains were observed on the draw sheet. The resident reported that linen is a concern at the facility. They stated that the linen currently on the bed had been there since last Saturday. They reported that the staff consistently state, We are out of linen.
During an interview on 02/20/2024 at 12:08 PM, Licensed Practical Nurse (LPN)8 came into the room and verified that BM was on the draw sheet and a brown ring was on the fitted sheet. She reported that Certified Nursing Assistant (CNA)2 was aware and would change linen after her break.
During an interview on 02/22/2024 at 9:02 AM, CNA2 confirmed that the flat sheet had a stain and fitted sheet was noted with a brown stain along with feces on the draw sheet. She stated, The reason it had not been changed was that she was waiting on clean linen to arrive because they were all out. When she asked about not having linens, she was told they were working on it. CNA2 reported that the resident has a bariatric bed and requires a larger size linens for his bed which was not available until after lunch when the Administrator brought the linens to her.
During an interview on 02/22/2024 at 10:23 AM, the Director of Nursing (DON) confirmed that there had been issues since January 2024 with not having enough linen related to changing companies which occurred the end of January. She reported the company only brought back the quantity/items received. She stated they store clean unused linen in the DON office, in the Assistant Director of Nursing (ADON) office, and on Unit 3 with the unit manager. Fitted sheets have been the main issue and they have used a flat sheet in place of a fitted to have a barrier on the mattress. On the bariatric beds they are using double flat sheets. The bariatric fitted sheets are identified with a blue or green trim. The delivery schedule used to be every Monday, Wednesday, and Friday but now is Tuesday, Thursday, and Saturday. There was an emergency delivery this week on Monday because on Sunday the Administrator was notified of a shortage and sent an email.
Review of R86's Face Sheet revealed R86 was admitted to the facility on [DATE] with diagnoses including but not limited to: spastic hemiplegia affecting left dominant side, anxiety disorder, other muscle spasm, contracture, left elbow, contracture, left wrist, primary osteoarthritis, right hand, pain in left arm, muscle wasting and atrophy, limitation of activities due to disability, other lack of coordination, and cerebral infarction.
Review of R86's Quarterly MDS with an ARD date of 11/21/23 revealed a BIMS score of 15 out of 15, indicating R86 was cognitively intact.
During an observation on 02/20/2024 at 11:34 AM, R86 was observed in bed on a mattress without a fitted sheet. He stated that the staff reports they are out of linen.
During an observation on 02/21/2024 at 8:42 AM, R86 was observed without a bottom sheet. R86 stated he wants a sheet on his mattress.
During an interview on 02/22/2024 at 3:45 PM, R86 reported that they got a fitted sheet for the bed yesterday and it was observed today on the bed.
During an interview on 02/23/2024 at 8:39 AM, CNA3 reported that everything the resident has said regarding the linen was true. She confirmed that there was not a fitted sheet on the mattress on Tuesday because there was not any. CNA3 confirmed that she had placed a fitted sheet on the mattress yesterday. She took the surveyor to linen room to show that this issue continues today. Only bath towels, flat sheets, and a few washcloths were observed. CNA3 stated there are never fitted sheets. She reported this has been an issue since last year around the holiday season. When the issue began, she asked housekeeping and was told they were switching companies but this has continued to be an issue for two months.
During an interview on 02/22/2024 at 10:23 AM, the DON confirmed that there had been issues since January 2024 with having enough linen related to changing companies which occurred the end of January. She reported the company only brings back the quantity/items received. They do store clean unused linen in the DON office, in the ADON office, and on unit 3 with the unit manager. Fitted sheets have been the main issue and they have used a flat sheet in place of a fitted to have a barrier on the mattress. On the bariatric beds they are using double flat sheets. The bariatric fitted sheets are identified with a blue or green trim. The delivery schedule used to be every Monday, Wednesday, and Friday but now is Tuesday, Thursday, and Saturday. There was an emergency delivery this week on Monday because on Sunday the Administrator was notified of a shortage and sent an email.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to ensure a privacy bag was provided to Resident (R)60's catheter bag for 1 of 2 residents reviewed. The deficiency disregarded the resident's privacy, dignity, and respect and had the potential to cause psychosocial harm.
Findings Include:
Review of the facility's policy titled, Patient/Resident Rights, with a completed revision date of 06/09/23, revealed, The Facility employs measures to ensure patient and resident personal dignity, well-being, and self-determination are maintained and will educate patients and residents regarding their rights and responsibilities. Residents Rights: A 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, recognizing each resident' individuality.
Review of R60's Face Sheet revealed he was admitted to the facility on [DATE] with the latest return being 02/18/24, with diagnoses including, but not limited to, obstructive and reflux uropathy, muscle wasting and atrophy.
Review of R60's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/02/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out 15, indicating R60 is cognitively intact.
Review of a Physician's Orders dated 04/29/21 indicated a Fig Privacy bag in place, every shift.
Review of R60's Treatment Administration Record (TAR) revealed on 02/20/24 through 02/22/24 indicated that staff documented that the Fig Privacy bag was in place.
Review of R60's Progress notes dated 01/03/24 revealed, Foley bag replaced with privacy covering.
During an observation on 02/20/24 at 3:25 PM, 02/21/24 at 4:49 PM, and 02/22/24 at 9:44 AM, revealed there was no privacy bag on R60's catheter bag.
During an interview on 2/22/24 at 9:44 AM with Registered Nurse (RN)4, she stated she would get a privacy bag for the resident and that they normally check and empty his catheter every day.
During an interview on 02/22/24 at 6:06 PM with the Director of Nursing (DON) revealed the hospital provided a new catheter to R60 and the expectations for the nursing staff would be to give him the correct privacy bag for the catheter. From now on, they will change the foley bag and check to make sure there is a privacy bag when a resident returns from the hospital.
During an interview on 2/23/24 at 10:34 AM with Licensed Practical Nurse (LPN)2, she stated she was not aware that she documented there was a privacy bag for R60 and there was not. She stated she does not remember and doesn't know what happened.
During an interview on 2/23/24 at 10:37 AM with LPN10, she stated that she can't recall why she would have documented that there was a privacy bag, she remembers R60 just came back from the hospital, but she is not sure if there was a privacy bag on there or not because that was her first time being on that unit. The only thing she remembers is doing the output and the catheter care.
During an interview on 2/23/24 at 11:08 AM with the facility Administrator, she stated the facility has fig bags, and they would normally be applied. R60 went to the hospital and when he returned, he had a new catheter and did not have a privacy bag. When it was identified by the surveyor, the RN changed it. When using a fig bag you have to change the whole catheter and that is why he didn't have one. The expectation is for staff to do their part, observe for any changes of signs and symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, observation, interview and record review, the facility failed to ensure proper cleaning of glucometers for 1 of 14 accu checks observed for glucometer cleaning. Resident (R)20 who received the accu check was at risk for obtaining other illnesses from the improper sanitization of the glucometer.
Findings include:
Review of the Policy and Procedures dated 1/12/24 and titled, Blood Glucose Monitoring, #11 states, Clean Glucometer utilizing 2-step process with approved EPAdisinfectant wipe which is labeled effective against TB or HBV, HCV, and HIV to remove any visible contaminants, soil, or other debris. Use a second EPD disinfectant wipe to disinfect the device surfaces, ensuring adequate contact time.
Review of MedLine EvenCare G2 Blood Glucose Monitoring System Users Guide pg 44-45 Cleaning and Disinfecting your EvenCare G2 Meter; revealed, Cleaning and disinfecting your meter .is very important in the prevention of infectious diseases. The following products are validated for disinfecting the EvenCare G-2 meter; Medline Micro-Kill Disinfecting cleaning wipes, Clorox Healthcare Bleach, Medline Micro-Kill Bleach Germicidal Bleach Wipes and Dispatch Hospital Cleaner Disinfectant.
A review of R20's medical record revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to; type 2 diabetes mellitus. Review of R20's orders revealed an order dated 11/13/23, which revealed, Insulin Lispro, per sliding scale coverage. Before meals and at bedtime .
On 2/21/24 at 1:33 PM, an observation of Registered Nurse (RN)1 on Station 2, Cart 2 revealed her performing an accu check on R20. RN1 put on gloves to perform the accu check, pricked resident's finger and then she wiped the blood with an alcohol prep pad. The reading was 153. She exited the room and placed the glucometer on her med cart surface. During an interview, RN1 stated, we should clean the machine before and after, right away. She confirmed it is best to have a barrier for the glucometer. She cleaned the glucometer machine with an alcohol prep pad and placed the glucometer back in the med cart. She stated, we don't have any other cleaner to clean with.
An observation of 7 additional medication carts revealed 3 of the 7 medication carts without Environmental Protective Agency (EPA) disinfectant wipes.
During an interview with RN2, who was working the 300 cart, RN2, on 2/21/24 at 1:45 PM stated, I use alcohol wipes to clean the glucometers.
Observation of the medication cart revealed there was no bleach wipes or Environmental Protective Agency (EPA) sanitizer observed on the med cart.
During an interview on 2/21/24 at 2:15 PM with Licensed Practical Nurse (LPN)1 on Unit 1, Cart 1, she stated, Today I cleaned the glucometer with alcohol wipes. I had Clorox wipes on my cart yesterday.
An observation of LPN1's medication cart revealed there were no EPA wipes or bleach wipes to clean the glucometer.
During an interview at the Station 2 Cart 1, an interview with LPN2 at 2:30 PM revealed, I cleaned the accu check glucometer with an alcohol prep pad today. I let it dry first.
An observation of LPN2's med cart revealed there were no EPA disinfectants or bleach wipes on her med cart.

Based on review of the facility policy, observation, and staff interviews, the facility failed to ensure proper sanitation of kitchen equipment and kitchen cleanliness.
Findings include:
Review of the facility policy titled, Sanitation and Food Safety in Food and Nutrition Services with a complete revision date of 6/20/2023 revealed Policy: The Certified Dietary Manager (CDM) will assume responsibility for the food safety and sanitation of the Nutrition Culinary Department. 4. The CDM monitors food safety and sanitation of the Food and Nutrition Department daily. 5. The CDM develops, implements, and monitors a cleaning schedule that assigns specific cleaning responsibilities to specific individuals.
During the initial walk-through of the facility kitchen on 2/20/2024 at 11:14 AM, the following observations in the kitchen were made with and verified by the Dietary Manager (DM):
1.
Broken and/or cracked floors were observed throughout the entire kitchen with small water puddles surrounding the cracked floors. There are visible cracks on the ground. The floor appeared filthy. Missing floor pieces. Discolored (Olive green) substance in small amounts throughout the kitchen floor.
2.
At 11:37 AM - A heavy accumulation of debris and what appeared to be coffee/tea grounds was observed on top and behind the coffee/tea maker. Dried brown and white substance running down the back of the machine.
3.
At 11:40 AM- Observation of facility industrial stove revealed a heavy accumulation of old food/grease debris was observed on the side and backsplash of the stove. Accumulation of grime was observed around the knobs and along the front side of the stove. The stove burners appeared rusted. The back of the stove had what appeared to be accumulated grime- a yellow/ brown substance (dried up) running down the back of the stove.
4.
At 11:42 AM Observation of the facility's industrial double-door revealed the oven was dirty. Both doors to the oven had an accumulation of grime/brown substance covering most of the front side of the oven. The windows to both oven doors appeared greasy and dirty. [NAME] substance throughout the doors.
5.
At 02:32 PM- An observation of a visible, concentrated amount of built-up, black colored grime was around the vents located by the three-compartment sink.
6.
At 02:34 PM- An observation of both kitchen doors leading to resident areas were dirty, with a visible amount of dirt and grime.
7.
At 02:36 PM- An observation of the kitchen ceiling light fixture cover located near the facility dishwasher was dark brown. The CDM and the Maintenance Director verified the ceiling light fixture cover is in need of replacement.
Walk-through of facility kitchen on 2/21/24 at 09:08 AM- The facility kitchen was in the same condition.
Walk-through of facility kitchen on 2/21/24 at 2:32 PM- The facility kitchen was in the same condition.
Walk-through of facility kitchen on 2/22/24 at 04:30 PM- The facility kitchen was in the same condition.
In an interview with the Dietary Manager (DM) on 2/20/24 at 11:45 AM, the DM stated that she has been employed for approximately 3 years. DM revealed that she agreed with all the findings. DM states that her kitchen staff is expected to do a deep cleaning once a week for the entire kitchen, and all equipment is to be wiped down after every use. End-of-day clean-ups are done daily by 8:30 PM, and night staff are expected to wipe down and ensure all equipment is left clean before leaving. DM states that she has brought up a lot of kitchen repairs to maintenance, and maintenance hasn't fixed the repairs. DM states that staff are to use mops to clean up the puddles of discolored water throughout the facility floor.
During an interview with the Facility Administrator (FA) on 2/22/2024 at 4:22 PM, she agreed with the kitchen findings and that the kitchen should be cleaner. The FA stated that her expectation of kitchen staff is to perform their duties related to kitchen deep cleans, and daily cleans along with the repairs to the kitchen floor. She stated she is aware of her kitchen being in those conditions and will consult with maintenance regarding fixtures/repairs.
In an interview with the Director of Maintenance (DOM) on 2/23/2024 at 10:10 AM, he stated that the kitchen staff is not doing a proper job of maintaining the equipment in the kitchen and that the equipment is less than 4 years old. The DOM stated that he has a maintenance log where the department head staff is to document what needs to be done and this is discussed during morning meetings, as well. The DOM stated the kitchen staff brought up the floors on 02/22/2024, which is documented on the log. The DOM stated if it's not documented on the log, there is no way for the Maintenance Department to know. The DOM stated some ceiling tiles have been replaced and he had no knowledge of the ceiling light fixture cover needing to be replaced.

Based on review of the facility policy, observation, interview and record review, the facility failed to ensure expired medications were removed from the medication and treatment carts, medication rooms; loose pills were removed from the medication carts, as well as failed to apply expiration dates on insulin pens for 4 of 4 units observed.
Findings include:
Review of the facility policy titled, Medication Storage, revised 4/1/2022, revealed 7. Once a multi packaged medication is opened, nursing will mark multi-dose products with the open dated date .
Review of the facility policy titled, Guidelines for Storage of Medications, revised 4/1/22, revealed 12. Outdated .medications . are disposed of according to procedures for medication destruction .
On 02/21/24 at 1:45 PM, an observation of 300 medication Cart 1 with Registered Nurse (RN)2, revealed 4 loose pills. RN2 confirmed the loose pills on the medication cart.
On 02/21/24 at 2:00 PM, an observation of 300 medication Cart 2 with RN4 revealed five insulin pens with open dates only, and 5 loose pills on the cart. During an interview on 02/21/24 at 2:03 PM, RN4 stated, The insulin pens should have written an expiration date, we should as nurses know how long the pens are good for.
On 02/21/24 at 2:15 PM, an observation of medication Cart 1 on Unit 1 revealed 6 insulin pens with open dates only. There was no other date was observed. An interview with Licensed Practical Nurse(LPN)1 revealed, We don't date the pens for the expiration, just the open date.
On 02/21/24 at 2:25 PM, an observation of Cart 2 on Unit 1 revealed 7 open insulin pens with an open date written on each pen. There was no other date observed. An interview with LPN4 confirmed there were no expiration dates on any of the open pens.
On 02/21/24 at 2:45 PM, Unit 4, Cart 2 an observation of Lantanaprost eye drops was open, but not dated and 7 loose pills observed in the bottom of medication drawer. LPN3 confirmed the eyedrops should be dated when opened and stated,We are to remove loose pills if we see them.
On 02/21/24 at 2:50 PM, Unit 4 Cart 1 an observation of insulin pens with date open written on each pen. There was no other date observed. There were 8 loose pills observed in the medication drawer. LPN5 stated, I'm not sure what the 1/7/24 date is for, I opened the pen on 1/29/2024 and it cannot be an expiration date. She confirmed loose pills are not to be found on the medication carts.
An observation of Unit 1's Med Room revealed on 02/22/24 at 3:30 PM, two Tuberculin injection vials that were both open, but neither with an open date. RN3 stated, They should be dated when they are open.
An observation of Unit 2's med room on 02/22/24 at 3:45 PM revealed a bottle of Personal Cleanser with expiration date of 10-2023. LPN2 stated, The Personal Cleanser bottle is expired, I will discard it.
An observation of Unit 3's Treatment Cart on 02/22/24 at 3:51 PM revealed, 2 Protective Ointment large tubes without an open date, with an expiration date of 01-2024. There was also Hydrogel Skin Integrity with an expiration date of 11/2022. LPN7 confirmed they were all expired.
An observation on 02/22/24 at 4:10 PM of Unit 4's med room revealed, two water bottles were observed in the medication refrigerator. An apple juice Motts, Med Plus 2.0 Butter Pecan x 2 opened were also in the medication refrigerator. There was also an open Tuberculin vial without an open date. A bottle of opened Acidophilus with an expiration date of 05/23 and a Flutic/Salm/Diskus dated 11/30/23 were also found. LPN8 confirmed the Tuberculin vial was open but not dated and confirmed the Acidophilus was expired. She stated, We don't have another refrigerator in the medication room to keep those items. There is a refrigerator on the unit used for resident snacks.
On 02/22/24 at 4:30 PM, Unit Manager LPN12 stated, All the treatments like tubes etc. need to be dated when open. There shouldn't be any expired treatments or medications in the cart or of residents who are no longer here. The TB vials should be dated on the vial and the box they are in.
On 02/23/24 at 10:45 AM, an interview with the Director of Nursing (DON) stated, My unit manager monitors the medication rooms and carts, she helps all units. They ensure the nurses are keeping the meds separated, liquids, eye drops, etc. Sometimes the nurses go through the carts in the morning if they've been off. We follow the pharmacy policies and nueses are required to date the insulin pens when they first use it and put the expiration date on the insulin pens as well. For lose pills they should dispose of them properly. The eye drops, creams, vials are to be dated after they've been open and no medication that has expired are to be on the medication carts.

Based on review of the facility policy, observation, interview and record review, the facility failed to ensure that residents are free of significant medication errors for 1 of 7 sampled Residents (R)43.
Findings include:
Review of the facility policy titled, Bedside Storage of Medications revised 4/1/2022, states 1. A written order for the bedside storage of medication is placed in the residents medical record 2. The interdisciplinary care team determines that a resident's capacity to self-administer using a self-medication assesment form documentaing any limitations.
On 02/20/24 at 10:47 AM, an observation revealed R43 in her room with medication at the bedside. The 30 milliliter medication cup was turned over on her bedside table with 4 pills still inside the cup. Registered Nurse (RN)2 was asked to come into R43's room. RN2 confirmed there were 4 pills in the medication cup that was turned over. He said he gave R43 her medication earlier in applesauce. RN2 then went back to the nurse's station to look up the pills and confirmed the medication matched the 6:00 AM medication. The medications were; 2 tablets were Acetaminophen 325 milligrams (mg) each, an Omeprazole 20 mg tablet and a small white rectangle tablet with the numbers 57 on the left and 55 on the right, indicating it was the narcotic, Methadone. RN2 took R43's Methadone card from the narcotic drawer and said, yes this is the pill. R43 takes it every 6 hours around the clock.
Record review on 02/22/24 of R43's orders revealed an order for Methadone 4 times a day, 12a-6a-12p-6p for pain. There was not a self assessment for medications at bedside, nor was there a care plan to self-administer medication.
An interview with the Director of Nursing (DON) at 3:24 PM on 02/22/24, revealed, Nurses cannot leave medications in the room at bedside. It's dangerous and they would need a locked box.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of 5% or less for 1 of 28 observations. The facility's medication error rate was 7.14%.
Findings include:
An observation of a medication administration on 2/23/24 at 9:30 AM revealed Licensed Practical Nurse (LPN)9 administered Magnesium 400 milligrams (mg) one (1) tablet to Resident (R)146. She also administered Advair Diskus to R146. After she administered the medication, she exited the room. She did not ask R146 to rinse his mouth and not to swallow after the rinse.
Record review of R146's orders revealed an order dated 01/25/24 for Magnesium Oxide tablet; 500 mg, one (1) tab; oral Once A Day. There was also an order dated 01/25/24 for Fluticasone Propion-Salmeterol blister with device; 500-50 microgram (mcg)/dose. Administer 1 puff inhalation. Special Instructions state, rinse mouth after use, do not swallow, twice a day at 08:00 AM, 04:00 PM.
An interview with LPN9 on 2/23/24 at 10:03 AM confirmed the observation. LPN2 acknowledged she gave Magnesium 400 mg, not 500 mg and pulled the bottle of Magnesium 400 mg and said, I just opened this today. She also stated, I did not tell R146 to rinse his mouth after giving him the Advair inhaler.

Based on observation, interview and record review, the facility failed to ensure professional standards of practice were followed regarding medication administration for 2 of 58 residents sampled. (Resident(R)43 and R146.
Findings include:
On 02/20/24 at 10:47 AM, an observation revealed R43 in her room with medication at the bedside. The 30 milliliter medication cup was turned over on her bedside table with 4 pills still inside the cup. Registered Nurse (RN)2 was asked to come into R43's room. RN2 confirmed there were 4 pills in the medication cup that was turned over. He said he gave R43 her medication earlier in applesauce. RN2 then went back to the nurse's station to look up the pills and confirmed the medication matched the 6:00 AM medication. The medications were; 2 tablets were Acetaminophen 325 milligrams (mg) each, an Omeprazole 20 mg tablet and a small white rectangle tablet with the numbers 57 on the left and 55 on the right, indicating it was the narcotic, Methadone. RN2 took R43's Methadone card from the narcotic drawer and said, yes this is the pill. R43 takes it every 6 hours around the clock.
An observation of a medication administration on 2/23/24 at 9:30 AM revealed Licensed Practical Nurse (LPN)9 administered Magnesium 400 mg, one (1) tablet. She also administered Advair Diskus to R146. After she administered the medication, she exited the room. She did not ask R146 to rinse his mouth and not to swallow after rinse.
Record review on 02/22/24 of R43's orders revealed an order for Methadone 4 times a day, 12 AM-6 AM-12 PM-6 PM for pain. There was not a self assessment for medications at bedside, nor was there a care plan to self administer medication.
Record review of R146's orders revealed an order dated 1/25/24 magnesium oxide tablet; 500 mg; amt: 1 tab; oral Once A Day.
Record review of R146's orders revealed an order dated 1/25/24 for fluticasone propion-salmeterol blister with device; 500-50 mcg/dose; amt: 1 puff; inhalation. Special Instructions: Rinse mouth after use. Do not swallow. Twice A Day at 08:00 AM, 04:00 PM.
An interview with the Director of Nursing (DON) at 3:24 PM on 2/22/24 revealed Nurses cannot leave medications in the room at bedside. It's dangerous and they would need a locked box.
An interview with LPN9 on 2/23/24 at 10:03 AM confirmed she administered Magnesium 400 mg and pulled the bottle of Magnesium 400 mg and said, I just opened this today. She also stated, I did not tell R146 to rinse his mouth after giving him the Advair inhaler.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interviews, review of the Facility Reported Incident (FRI), the facility failed to ensure one of 15 sampled residents (Resident (R)1), who had a physician order for a pureed diet and nectar thickened liquids received adequate supervision to remain free from accident hazards. Specifically, R1 obtained a pimento cheese sandwich from the evening snack cart and consumed some of the sandwich, as a result, R1 was found unresponsive while seated in a wheelchair in his room. Staff immediately initiated cardiopulmonary resuscitation (CPR). The nurse staff found pieces of the pimento cheese sandwich in R1's mouth. This failure placed the resident at risk causing serious injury, serious harm, and death.
On 05/01/23 at 7:18 PM, the survey team provided the Administrator and Director of Nursing (DON) a copy of the CMS Immediate Jeopardy (IJ) Template and notified them that an IJ existed on 04/29/23 and constituted Substandard Quality of Care (SQC). The IJ and SQC were related to 42 CFR 483.25 - Accidents (F689).
On 05/02/23 at 9:00 AM, the facility presented a copy of their Corrective Action Plan dated 05/01/23. On 05/02/23 at 4:02 PM, the survey team validated that the facility removed the IJ as of 05/01/23, before the survey entrance. IJ at F689, severity J, cited as Past Non-compliance.
Findings include:
Review of R1's electronic face sheet located in the face sheet tab revealed R1 was admitted to the facility on [DATE] and had a readmission date of 03/02/23 with diagnoses including cerebral infarction, dysphagia following cerebral infarction (History of) and unspecified convulsions. Review of the resident's electronic physician's orders located on the orders tab revealed R1 had an order for honey thickened liquids, at risk for swallowing/choking, assist with feeding, pureed meals, and Speech Therapy (ST) to evaluate and treat for dysphagia.
Review of the electronic annual Minimum Data Set (MDS) located under the MDS tab dated 03/24/23 revealed R1 has a BIMS score of 2 out of 15, which indicated the R1 was severely impaired, required supervision/one person assist while eating, and no speech therapy triggered at this time.
The electronic Care Plan located under the care plan tab dated 04/04/23 identified R1 as having episodes of insomnia as manifested by not sleeping well at night, unable to stay asleep, and is at risk for alteration in nutrition related to dementia, weight loss, dysphagia with modified texture diet speech therapy related to dysphagia as needed.
Review of the Incident Report, dated 04/29/23, revealed, R1 was identified by Licensed Practical Nurse (LPN)1 in his room in his wheelchair appearing to be asleep. LPN1 identified R1 was unresponsive and immediately called a code blue upon confirming R1's code status. LPN1 identified R1 to have pieces of a pimento cheese sandwich in his mouth when CPR was initiated. R1 was on a pureed diet with nectar thick liquids and was severely, cognitively impaired, and not capable of making safe decisions.
During an interview on 05/01/23 at 12:14 PM, the Administrator stated that on 04/29/23 at 3:25 AM, a Certified Nurse Aide (CNA)1 on 200 hall saw R1 at the nurses' station sitting in his wheelchair and then observed R1 propel himself to his room. The Administrator stated that on 04/29/23 at 3:42 AM, LPN1 was walking down the hall and passed the resident's room and noticed the resident appeared to be asleep sitting up in his wheelchair. LPN1 entered the room and tried to wake R1, so that he could be transferred to the bed to rest. LPN1 noticed that R1 didn't respond. LPN1 determined that R1's skin was warm to touch, body movements were flaccid and no signs of a struggle. The Administrator stated that LPN1 realized that the resident didn't respond to physical stimulation and was unresponsive. LPN1 verified the resident's code status, by reviewing R1's face sheet, and initiated a code blue. CNA1 called 911. LPN2 came from the 300 hall to assist LPN1 with the code blue. The Administrator stated LPN1 identified R1's mouth was opened while initiating CPR, and observed a piece of a pimento cheese sandwich in R1's mouth. LPN1 removed the sandwich and CPR was initiated until EMS arrived. EMS arrived on 04/29/23 around 3:54 AM and EMS took over the code and called the time of death at 4 AM on 04/29/23. Continued interview with the Administrator revealed the nurse stated the resident somehow got the half pimento cheese sandwich from the snack cart for bedtime. Some of the sandwich was found behind R1 in his wheelchair.
During an interview on 05/01/23 at 1:01 PM, LPN1 confirmed being the nurse on the 200 unit for the night and that she saw R1 around the nurses' station on 04/29/23 around 2:50 AM asking for more food. LPN1 confirmed R1 was on a pureed diet with nectar thick liquids. She stated she gave R1 the apple sauce off the snack cart. LPN1 stated she was getting ready to go to a different nurses' station when she went down the hall around 3:40 AM. LPN1 noticed R1 was in his wheelchair and appeared to be asleep. LPN1 stated his body was limp, skin was warm to touch, and body was flaccid. LPN1 checked his pulse on his wrist and neck and checked the resident for breathing. LPN1 stated she ran to the nurses' station to identify resident's code status and immediately called the LPN2 on unit 3 for assistance. LPN1 stated she got the crash cart and went to R1's room around 3:43 AM. LPN1 alerted the CNAs of the code blue being performed on the resident. LPN1 stated she and CNA1 were able to get the resident on the bed to perform CPR. There was another CNA who called 911 around 3:45 AM and told 911 it appeared that resident had probably aspirated. LPN1 stated she removed the sandwich from the resident's mouth. She confirmed she started doing compressions and suctioned food from the resident's mouth. LPN1 stated EMS arrived around 3:55 AM and took over CPR. The EMS connected R1 to an AED (Automated external defibrillator) and called R1's time of death around 3:58 AM. LPN1 stated she typically keeps snacks behind the nurse's station. She stated one of the CNAs blocked off the nurse's station to keep the resident from going to the snacks. She stated one of the CNAs later indicated the item used to block the nurse's station was pushed back and it appeared someone had moved it. LPN1 stated she doesn't particularly know where R1 got the sandwich. LPN 1 indicated R1 would ask for snacks, and this is why they would block the nurse's station at night.
During an interview on 05/01/23 at 1:37 PM, CNA1 stated she was working with another CNA. CNA1 confirmed that she did not feed R1 any food or snacks. CNA1 stated that she was unaware of R1's diet. CNA1 stated she saw him by the nurses' station around 2:30 AM, completed rounds around 3:25 AM and later observed LPN1 running with the crash cart to R1's room. CNA1 stated she saw the resident in his wheelchair with head back and mouth open. She stated she called 911 immediately. EMS arrived and called R1's time of death.
During an interview on 05/01/23 at 2:44 PM, the Director of Speech (DOS) stated that R1 was on speech therapy's caseload from 04/20/22 - 08/02/22. She stated the resident was last screened March 2023 and there were no changes to R1's diet as it was already pureed with nectar thick liquids and was still appropriate at the time of screening.
During an interview on 05/01/23 at 5:36 PM, the Administrator stated the snack cart would be placed right near the nurse's station with bedtime snacks. The snacks are labeled and dated. The Administrator stated that CNA1 indicated the snacks were placed on the cart during the ice pass and she forgot to remove the snacks after completing the ice pass. The Administrator stated during that time of the night the snacks should be placed behind the nurse's station.
During an interview on 05/01/23 at 5:44 PM, the DON confirmed there are other residents who are on a pureed diet, but they do not take food.
During an interview on 05/01/23 at 5:48 PM, the Dietary Manager (DM) confirmed the bedtime snacks consisted of half sandwiches peanut butter and jelly, egg salad sandwiches and pimento cheese. Other snacks include pudding cups, applesauce, and fruit cups. She stated there are 18 residents who have a physician's order for pureed diet and snacks provided for the puree residents are pudding cups, puree fruit (available upon request), and apple sauce.
During an interview on 05/01/23 at 5:51 PM, CNA2 stated she has been educated on resident's diet. She stated the snacks were kept behind the nurse's station after being passed out to residents. She stated the residents have meal cards to identify the resident's diet and if there are no meal cards available, she will refer to the nurse for the resident's diet.
During an interview on 05/01/23 at 5:57 PM, Registered Nurse (RN1) stated the resident's diet is listed on the diet sheet and on the 24-hour report. She stated the snacks are kept behind the nurse's station or in the medication room. She stated the snacks are passed out by the direct care staff and leftovers are placed behind the nurse's desk or in the medication room. She stated that R1 would always let staff know when he wanted a snack. She stated the resident would always have a snack off of the snack cart which included pudding, applesauce, or jello. She stated the resident was supervised each time for feeding including meals. She was educated after the incident, on placing the snacks in the medication room and reviewing resident's diet before providing the resident a snack.
During an additional interview on 05/01/23 at 6:06 PM, the Administrator stated during the investigation process for R1, residents who were identified as wanders, diet was compared, and behaviors were reviewed. The facility determined that there are no current residents at risk for wandering and consuming food not appropriate to their diet. The Administrator indicated that all staff have been trained to store the snack cart in the medication room.
The facility's Corrective Action Plan dated 04/29/23 included the following:
Summary of Incident:
On 04/29/23, R1 was identified to have a pimento cheese sandwich in his mouth when CPR was initiated. R1 was on a pureed diet with nectar thick liquids. R1 was severely, cognitively impaired, and was not capable of making safe decisions.
Immediate Action:
On 04/29/23, the DON immediately implemented education on not leaving snack carts unattended, placing all snacks in the nourishment room, and monitoring all residents during mealtimes, snack times and activities including food/drink items.
On 04/29/23, the DON investigated and conducted a root cause analysis of the incident. The investigation revealed R 1 was identified to be warm to touch flaccid with no bluish discoloration around mouth or gums on initial encounter. CNAs interviews with the DON established R1 was able to retrieve the pimento cheese sandwich from the snack cart and the nurses confirmed sandwich bag underneath resident when R1 was transferred from the wheelchair.
Identification of others:
Between 04/29/23 to 05/01/23, similar residents were assessed and were confirmed to not be at risk for wandering and retrieving food items. No other residents were affected by the deficient practice.
Action taken:
Interview on 05/03/23 at 10:57 AM, LPN2 confirmed being educated on Monday, 05/01/23 about monitoring all resident with meals, and when snacks are brought out to lock up all snacks, no drinks are allowed at the nurse's station, personal items and staff was also educated on reviewing resident's diet or meal ticket prior assisting residents with snacks or meals.
Interview on 05/03/23 at 11:22 AM, RN2 confirmed being educated on supervising meals, any snack drinks etc. must be placed away so that it's not in the resident's reach. Educated on Monday morning, 05/01/23.
Interview on 05/03/23 at 11:24 AM, the CNA/payroll and staffing confirmed when snacks come to the hall, all snacks need to be placed in a locked room. All residents are to be supervised during snack and mealtimes. Educated on identifying the resident diet order by looking at the meal ticket before assisting with meals.
Interview on 05/03/23 at 11:45 AM, Dietary1 stated anyone with minced/pureed diets, snacks must be put away, so no residents have access to the snacks. The dietary hands the snacks to the nurses and the nurses are to place the snacks in the medication room and lock the door.
Interview on 05/03/23 at 11:49 AM, CNA3 stated that all residents are to be supervised; snacks are to be kept in a locked room. Educated on learning the resident's diet and verifying diet prior to meal, snacks, or activities. When meals or any food is out staff is to remain in visible sight of residents especially residents with altered diets to ensure safety.
Nursing and dietary staff will continue to check placement of snacks to be safely secured and all meals and activities involving meals to be monitored by staff. Documentation was reviewed and verified during the survey.
There was Quality Assurance and Performance Improvement a (QAPI) meeting held on 05/01/23 at 10:00 AM. The facility will continue to review residents at risk for choking accident hazards and revise the Corrective Action Plan as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to develop and implement a discharge plan for one (1) of two (2) residents, Resident #142, reviewed for discharges.
Findings include:
Review of the facility's Discharge Planning policy, with a revision date of 10/1/2020 revealed, POLICY: 1. Social Services staff, as members of the Interdisciplinary Team, will participate in the development of a discharge plan for patients or residents . PROCEDURES: . 5. When the Interdisciplinary Team determines that a patient/resident has potential; or the resident expresses a desire for discharge, Social Services staff addresses the following information utilizing Discharge Summary in Matrix or discharge plan/instructions form which is contained in the resident's medical record .
Review of Resident #142's Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses to include: Acute Kidney Failure, Paraplegia and Essential Hypertension. Resident #142 was discharged on 11/3/21 to another skilled nursing facility.
Review of the Resident Progress Notes dated 11/3/21, revealed Resident #142 was picked up by transport and left the facility at 5:25 a.m. via (by way of) stretcher. The resident signed for his/her meds and took his/her belongings with him/her.
Review of Resident's #142's medical record revealed a Minimum Data Set (MDS) Assessment which indicated the resident had a planned discharge with return not anticipated on 11/3/21.
Interview on 1/13/22 at 11:25 a.m., the Social Service Assistant (SSA#1) stated Resident #142's representative asked for Resident #142 to be transferred to a facility closer to the representative. SSA#1 stated s/he reached out to a different facility and sent all the appropriate paperwork to them. SSA#1 stated s/he set up transportation but didn't document any of the planning that went into transferring Resident #142 because it was all in his/her head. SSA#1 stated s/he forgot to document the discharge planning.
In a follow-up interview on 1/13/22 at 11:41 a.m., SSA#1 stated s/he was responsible for resident discharges.
Interview with Administrator on 1/13/22 at 12:04 p.m., revealed the SSA#1 was responsible for discharges.

Based on observation, review of facility policy, cleaning schedules, and interview, it was determined the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Sanitation concerns were identified in all areas of the kitchen and had the potential to affect 144 of 151 residents who received meals from the kitchen.
Findings include:
Review of the facility's policy titled Nutrition Policies and Procedures with the subject Sanitation & Food Safety in Food and Nutrition Services revised 8/1/2020 revealed the Nutrition Services Director (NSD) (Certified Dietary Manager) will assume responsibility for the food safety and sanitation of the Nutrition Culinary Department.
Procedures outlined included:
1) Infection control and sanitation practices are followed to minimize the risk of contamination of food and prevent food borne illness.
2) The NSD monitors food safety and sanitation of the Food and Nutrition Department daily.
3) The NSD develops, implements, and monitors a cleaning schedule that assigns specific cleaning responsibilities to specific individuals. Cleaning tasks are initialed as they are completed.
4) The Sanitation Review is completed monthly by the Dietitian and copied to the Administrator.
5) The NSD/Dietitian reviews and evaluates the data collected and determines the plan of action necessary to resolve any problems identified.
6) The audit and the action plan are submitted to the Administrator and the facility quality improvement coordinator/infection control coordinator.
7) The NSD provides written cleaning instructions for each area and piece of equipment in the kitchen.
Review of the facility's dietary cleaning schedule checklists developed to document verification of daily Cleaning Schedule and Weekly Deep Cleaning Schedule revealed the checklists were not being completed as verification that cleaning had occurred. A review of the daily Cleaning Schedule checklists for December 2021 and January 2022 revealed areas identified as requiring daily cleaning such as floors, steam table, and steamer were documented as being cleaned one (1) to two (2) times weekly. The Weekly Deep Cleaning Schedule checklist was blank and had not been documented as being done for November and December 2021 or January 2022.
An initial tour of the kitchen was conducted on 1/11/22 at 7:23 a.m. Dietary staff were in the process of serving the breakfast meal from the steam table. A brief observation of the food storage, food preparation, and food service areas revealed concerns regarding cleanliness of floors, equipment, and ventilation areas.
An in-depth environmental tour of the kitchen was conducted on 1/12/22 at 11:29 a.m. Concerns identified during each of the tours with professional standards for food service safety included:
- Range hood noted to have a build up of dust and debris located in the vents.
- Ice machine outside of unit noted to have a dust, debris, and dirt build-up. Sticky to touch on the outside of unit.
- A build-up of dirt and debris noted under the slotted shelves where dry foods were stored.
- Shelves in dry food storage areas where food products were stored contained dust and debris, some were sticky to touch.
- Wall area behind where steam table pans were stored was noted to be sticky with large amounts of dust and dirt stuck to the walls.
- A 3-tier and a 4-tier cart were each observed positioned at the steam table. The 3-tier cart contained resident trays for use during the meal service. The 4-tier cart contained pre-poured milk and juice to be served to residents. Each of the carts was noted to be dirty and sticky to the touch. The carts had been scratched up with usage and the scratches had dirt build-up inside them. The bottom shelf of the 4-tier cart had a pool of murky water on it from leakage above.
- A 3-tier cart was observed to have two (2) loaves of bread and a bag of chopped lettuce lying on the top shelf. The food items were being used in preparation for the noon meal service. The cart was pushed up to and touching a large trash can that contained garbage.
Interview was conducted on 1/11/22 at 7:42 a.m. with the Certified Dietary Manager (CDM). The CDM stated the facility did have a contract with an outside company to professionally clean the range hood. However, the invoice for the last time the range hood was cleaned had not been paid and the company had refused to provide the service again until payment was received. The CDM stated the issue was just an error of the invoice not being paid and s/he anticipated it would be paid soon. The CDM stated the dietary staff were not able to follow the cleaning schedules because the dietary department was short-staffed. The CDM acknowledged the identified sanitation concerns and stated the kitchen needed a good cleaning.
Interview was conducted on 1/11/22 at 7:26 a.m. with the Head [NAME] (HC) working in the dietary department. The HC stated there was really no time available to clean the dietary department. The HC stated s/he worked to prepare and serve resident meals and would clean up after him/herself after serving resident meals. However, this did not include detailed cleaning of areas not used during the meal preparation and service.
Interview was conducted on 1/12/22 at 12:05 p.m. with the Interim Administrator. The Interim Administrator had been at the facility for three (3) days and had not had an opportunity to tour the dietary department. The Interim Administrator stated the former Administrator should have been working with the CDM to make sure the dietary department was maintained in a sanitary and clean manner. The Interim Administrator accompanied the surveyor on a brief tour of the dietary department. The Interim Administrator acknowledged the areas of concern with sanitation and stated the kitchen needed to have a deep cleaning, be painted, and old equipment replaced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a discharge summary for one (1) of two (2) residents, Resident #142, reviewed for discharges.
Findings include:
Review of the facility's policy titled Discharge Summary revised 10/1/2020 read in part: . 2. The Discharge Summary is completed when the patient or resident is permanently discharged for any reason and return to the facility is not anticipated. The completed Interdisciplinary Discharge Summary is part of the patient/resident's closed medical record .
Review of Resident #142's Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses to include: Acute Kidney Failure, Paraplegia and Essential Hypertension. Resident #142 was discharged on 11/3/21 to another skilled nursing facility.
Review of the Resident Progress Notes dated 11/3/21, revealed Resident #142 was picked up by transport and left the facility at 5:25 a.m. via (by way of) stretcher. The resident signed for his/her meds and took his/her belongings with him/her.
Review of Resident #142's medical record revealed a Minimum Data Set (MDS) Assessment which indicated the resident had a planned discharge with return not anticipated on 11/3/21.
Review of Resident #142's medical record did not include a completed Discharge Summary.
During an interview on 1/13/22 at 11:25 a.m., the Social Service Assistant (SSA#1) stated Resident #142's representative asked for Resident #142 to be transferred to a facility closer to the representative. The SSA#1 stated s/he reached out to a different facility and sent all the appropriate paperwork to them. SSA#1 stated s/he set up transportation but didn't document any of the planning that went into transferring Resident #142 because it was all in his/her head. S/he stated the nurse did a nurse's note but did not state where the resident was discharged to. The SSA#1 stated s/he forgot to document the summary and discharge planning.
In a follow-up interview on 1/13/22 at 11:41 a.m., the SSA#1 stated s/he was responsible for resident discharges.
Interview with Administrator on 1/13/22 at 12:04 p.m., revealed the SSA#1 was responsible for discharges. The Administrator stated normally discharges are discussed in morning meetings and each discipline was responsible for completing their part on the resident's discharge summary. The Administrator stated it was the SSA#1 responsibility to ensure the summary was complete and that each disciple completed their portion. The Administrator acknowledged Resident #142's Discharge Summary was not completed.
Interview on 1/13/22 at 2:30 p.m., the National Social Work Consultant (NSWC#1) revealed the Discharge Summary was to be completed by the Interdisciplinary Team (IDT) and the SSA#1 was supposed to ensure the summary was complete and sent with the resident upon discharge and to the transferring facility. The NSWC#1 confirmed Resident #142's Discharge Summary was not completed.