Marion Regional Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of a facility policy titled, Nebulizer Masks, Tubing and Bag Protocol, the facility failed to ensure Resident Identifier (RI) #13's oxygen tubing was labeled/dated; and further failed to ensure RI #34, RI #37, and RI #263's nebulizer masks were covered when not in use. This deficient practice affected four of five residents sampled for respiratory care. Findings Include: A review of a facility policy titled, Nebulizer Masks, Tubing and Bag Protocol, with a last modified date of 02/12/2025, documented: . Rationale: To provide infection control and protection for residents using nebulizer treatments. Policy: It is the policy . that nebulizer masks and tubing should be dried and stored when not in use. Procedure: . 2. The residents name . and the date should be written on the bag, tubing and mask . RI #13 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease. RI #13's physicians orders dated 11/20/2024…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, resident record review, and review of a facility policy titled Resident's Rights: Privacy and Confidentiality the facility failed to honor resident privacy rights when Certified Nursing Assistant (CNA) #10 failed to knock on doors and gain permission to enter, before entering resident rooms on 02/18/2025 during the evening dining observation. This affected Resident Identifier (RI) #28 and RI #32, two of 19 sampled residents. Findings include: Review of a facility policy titled Resident's Rights: Privacy and Confidentiality with a review date of 03/2020, revealed the following: . Policy: It is the policy of [NAME] Regional Nursing Home that residents' confidentiality and privacy should be protected. Procedure: 1. Residents . have the right to- . b) Privacy while in their rooms. Staff should respectfully knock on doors or verbally announce the request to enter the room prior to entry. RI #32 was admitted to the facility on [DATE]. RI #28 was admitted to the facility on [DATE]. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review, interviews, review of a facility policy titled Protecting Residents from Abuse, Neglect and Exploitation, review of the facility investigative file, and review of a Facility Reported Incident (FRI) to the State Agency, the facility failed to protect Resident Identifier (RI) #25's right to be free from abuse on 09/14/2024 when RI #313, a resident with unmanaged behaviors, hit RI #25 in the face. RI #25 described the incident as abusive. This deficient practice was cited as a result of the investigation of the complaint/report number AL00048923 and affected RI #25, one of two residents sampled for abuse. Cross Reference F740 Findings include: A facility policy titled, Protecting Residents from Abuse, Neglect, and Exploitation documented: . Policy: It is the policy of [NAME] Regional Nursing Home to protect residents from abuse. This includes but is not limited to verbal, physical, mental/emotional, . Procedure: . When protecting residents from abuse, utilizes the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Resident Assessment Instrument 3.0 Manual, the facility failed to ensure: 1) Resident Identified (RI) #23's annual Minimum Data Set (MDS) assessment dated [DATE] section A1500 was coded accurately to reflect RI #23's Preadmission Screening and Resident Review (PASRR) Level II. 2) RI #25's annual MDS assessment dated [DATE] section A1500 was coded accurately to reflect RI #25's PASRR Level II. This deficient practice affected two of 19 sampled residents whose MDS was reviewed. Findings include: Review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2024, revealed the following: . A1500: Preadmission Screening and Resident Review (PASRR) . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition 1) RI #23 was admitted to the facility on [DATE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, resident record review, and review of the facility's investigative file, the facility failed to develop and implement immediate interventions to prevent other residents from being affected by Resident Identifier (RI) #313's behaviors. The facility failed to develop targeted care plans to assist in resolving RI #313's behaviors, failed to monitor RI #313 for behaviors that led to abuse, and failed to assess RI #313's required level of supervision to protect other residents. On 09/13/2024, RI #313's Nurses' Notes documented that RI #313 was exhibiting hostile behavior, resisting care, taking others' belongings, and becoming very agitated when requests were made. On 09/14/2024, RI #313 continued to have behaviors including taking RI #25's, his/her roommate's, belongings which resulted in RI #313 hitting RI #25 in the face. This deficiency was cited as a result of the investigation of complaint/report number AL00048923 and affected RI #25 one of six residents sampled for behavior concerns. Cross…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, review of Resident Identifier (RI) #34's medical record, and a facility policy titled Psychotropic Medication Utilization the facility failed to ensure RI #34 was not ordered and administered a PRN (as needed) antipsychotic medication, Haldol, for greater than 14 days, without documented rationale in the resident's medical record for the continued use of the PRN antipsychotic medication. This deficient practice affected RI #34, one of six residents sampled for unnecessary medications. Findings include: A review of a policy titled Psychotropic Medication Utilization documented: Rationale: To provide guidelines for the utilization of psychotropic medications. 10. Psychotropic medications used on a PRN (as needed) basis should have a specific condition and indication for the PRN use documented in the resident's medical record and is subject to limitations as noted: . a. PRN orders for psychotropic medications, excluding antipsychotics should be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of the facility's Procedure for Passing Meal Trays, the facility failed to ensure Certified Nursing Assistant (CNA) #10 distributed residents' meal trays in a manner to prevent the spread of infection between himself and residents. CNA #10 failed to perform hand hygiene before handling and delivering dinner meal trays for Resident Identifier (RI) #28 and RI #32 from the meal cart on 02/18/2025 during the evening dining observation. This deficient practice affected RI #28 and RI #32, two of 19 sampled residents. Findings Include: Review of an undated procedure form titled, Procedure for Passing Meal Trays, revealed the following: . 5. Staff should perform hand hygiene between each resident . RI #32 was admitted to the facility on [DATE]. RI #28 was admitted to the facility on [DATE]. On 02/18/2025 at 5:11 PM the surveyor observed CNA #10 removed RI #32's dinner meal tray from the meal cart without performing hand hygiene. CNA #10 entered RI #32's room,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, medical record reviews and review of a facility policy titled, Care Plan Policy, the facility failed to ensure baseline care plans were developed within 48 hours of admission for the following Resident Identifier (RI) #'s and investigated care areas: 1. RI #36, tube feeding, risk for falls, nutrition, range of motion, 2. RI #30, Dementia, psychotropic medications, 3. RI #12, oxygen use, 4. RI #18, risk for falls, Dementia, psychotropic medication, 5. RI #21, Dementia, psychotropic medications, and 6. RI #34, tube feeding and insulin use. This deficient practice affected RI #36, 30, 12, 18, 21 and 34, six of 16 residents whose care plans were reviewed. Findings Included: A review of a facility policy titled, Care Plan Policy, with a Revised Date: 9/19, revealed: . Procedure: . A baseline care plan should be developed within 48 hours of a resident's admission . Must provide the resident and their representative with a summary of the baseline care plan. All assessment and care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, medical record review and review of a facility policy titled, Oxygen Concentrator Humidifier Bottles, Tubing and Filter Care, the facility failed to ensure Resident Identifier (RI) #12 had water in his/her humidifier bottle during three of three days of the survey. This deficient practice affected RI #12, one of three residents sampled for oxygen (O2) use. Findings Included: A review of a facility policy titled, Oxygen Concentrator Humidifier Bottles, Tubing, and Filter Care, with a last reviewed date of 9/19, revealed: . Procedure: 1. O2 concentrator humidifier bottles will be checked each 12 hr (hour) shift by the LPN (Licensed Practical Nurse) for adequate water levels. Task will be verified by a Long Term Task Order. RI #12 was admitted to the facility on [DATE], with a diagnosis to include, Chronic Ischemic Heart Disease, unspecified. A review of RI #12's medical record document titled, Order List By Department, revealed: . Respiratory Care . Oxygen Therapy . Date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and a facility document titled Annual Training Protocol, the facility failed to ensure Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA), received the mandatory 12 hours of Continuing Education Units (CEUs) for annual training, to include dementia and abuse training, from 7/25/2018 to 7/25/2019. This affected one of five CNA's whose mandatory 12 hours of CEUs for annual training to include dementia and abuse training that were reviewed. Finding include: A review of a facility document, titled Annual Training Protocol with no date, revealed . 3. Annual Education Topics: * Abuse * Dementia . 4. Training for Nurse Aides will be 12 hours per rolling year from hire date. A review of EI #1's mandatory annual 12 CEU training, which was to include Dementia and Abuse Training, revealed that EI #1 was hired to the facility on 7/25/2016. From 7/25/2018 to 7/25/2019 she had received only 7.5 CEU hours, which did not include Dementia and Abuse training. EI #1 did not meet the required mandatory annual 12 CEUs, to include with Dementia and Abuse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of a facility policy titled FOOD AND SUPPLY STORAGE and REFRIGERATED STORAGE LIFE OF FOODS, the facility failed to ensure chicken salad in a black plastic container and 4 pieces of toffee cake in a disposable plate, with no date documented for date opened and no use by date, were dated. This had a potential to affect sixty-three out of sixty-five residents receiving meals from dietary. Findings Include: A review of the facility policy titled FOOD AND SUPPLY STORAGE, with a revised date of 1/18, documented: .PROCEDURES: .The words .use-by . should precede the date .Foods past the use by .date should be discarded .label and date unused portions . A review of the facility policy titled REFRIGERATED STORAGE LIFE OF FOODS, with a date of January, 2018, documented: .Label when product is opened. The time listed is added to today's date . Food Item . Commercially Prepared Salads .OPENED .+3 days . On 08/06/18 at 4:30 p.m., during the kitchen tour with Employee Identifier (EI) #1, an Interim Dietary Manager, the surveyor observed the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and a facility policy titled, Resident Rights :Privacy and Confidentiality, the facility failed to ensure RI (Resident Indentifer) #213 MAR ( Medication Administration Record) computer screen was not left up/unlocked and open for public view. This deficient practice affected RI #213 one of 16 sampled residents. Findings Include: A review of a facility policy titled, Resident Rights :Privacy and Confidentially, with a revised date of 10/17 revealed: Rationale: To provide guidelines to help preserve and protect residents confidentiality and privacy Procedure: .(B) Confidentiality for his/her personal and clinical records. Ensure that Med cart lab top screens are not easily viewed by anyone other than Nurse administering medications and that screen is neutral or top is closed when exiting workstation. Ensure that .computers are logged off before exiting workstation. RI #213 was readmitted to the facility on [DATE]. Diagnoses included major depressive disorder, recurrent severe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and a review of a facility policy titled Medication Administration, the facility failed to ensure a Licensed Practical Nurse (LPN), did not touch inside the medication cup, water cup, and pill crush bag with her bare finger when administering medication to Resident Identifier (RI) #61. This affected one of two residents observed during medication administration who received medication by Percutaneous Endoscopic Gastrostomy (PEG) Tube. Finding Include: RI #61 was readmitted to the facility on [DATE] with diagnoses to include Unspecified Dementia with Behavioral Disturbance, Gastro-Esophageal Reflux Disease, Esophageal Obstruction, and Encounter for Attention to Gastrostomy. Review of a facility policy titled Medication Administration last revised date September 2015, revealed, . Procedure: . Medication Administration: . 5. Medications should be given maintaining aseptic technique. Inside the medicine souffle cup, plastic med cup, or crush pouch should not be touched. On 8/7/18 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.