Magnolia Manor - Spartanburg

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, record review and interview, the facility failed to notify the provider of a dehisced wound for 2 days, which caused Resident (R)8 to return to the hospital, for 1 of 1 residents reviewed. Findings include: Review of the facility policy dated 06/01/15, titled, Surgical Incisions documents, The clinician will follow specific physicians orders for treatment of these wounds. Obtain clarification orders if the initial orders are not specific. These wounds are usually covered with dry dressings. Based on review of facility policy, record review and interview, the facility failed to notify the provider of a dehisced wound for 2 days, which caused Resident (R)8 to return to the hospital, for 1 of 1 resident reviewed. Findings include: Review of the facility policy dated 06/01/15, titled, Surgical Incisions documents, The clinician will follow specific physician's orders for treatment of these wounds. Obtain clarification orders if the initial orders are not specific. These wounds are…

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 review of the facility policy, observation, record review and interview, the facility failed to ensure ordered fall devices were in place for 1 Resident (R)11, reviewed for accidents. Findings include Review of the facility policy titled, Fall Management with a revision date of May 5, 2023 revealed under the policy, The facility will identify each resident who is at risk for falls and will plan care and implement interventions to manage falls. The facility provides assistive devices based onindividual resident needsto facilitate mobility and prevent falls. Record review of R11's facesheet revealed he was admitted to the facility on [DATE] with diagnoses that include but are not limited to; displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Record review of R11's Quarterly Minimum Data Set (MDS) with an Assesment Reference Date (ARD) of 12/02/24…

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 review of facility policy, observation, interview and record review, the facility failed to report an allegation of physical abuse, involving Resident (R)2, within the required timeframe, for 1 of 4 residents reviewed for abuse. Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation, or Mistreatment revised on 10/23/19, documents, The facility's Leadership prohibits neglect, mental, physical, and or verbal abuse . and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment . are reported immediately. Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE], with diagnoses including but not limited to: chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, unspecified depression and cerebrovascular accident. Review of R2's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/02/24, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating R2 had…

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 observations, interview, record review, and facility policy review, the facility failed to ensure a nurse followed physician orders and manufacturer's guidelines for administering an inhaled corticosteroid for 1 out of 29 opportunities of medication administration. Findings include: Review of a facility policy titled, Nursing Policies and Procedures, dated 05/05/2023, revealed, 6. The authorized staff member reads the label on the medication three times. A. Before removing the medication from the drawer, before dispensing the medication, and after dispensing the medication. 13. The authorized staff member administers medications according to accepted standards of practice and in compliance with regulatory requirements. Review of the GlaxoSmithKline instructions for use of Trelegy Ellipta, with a revised date of December 2022, revealed under Step 6, Rinse your mouth with water after you have used the inhaler and spit the water out. Do not swallow the water. Review of an admission Record indicated the facility admitted Resident (R)87 on 06/04/24 with diagnoses including but…

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, record review, interviews, and review of the facility policy, the facility failed to follow physician orders for oxygen administration for 1 of 1 residents reviewed for respiratory care, Resident (R)41. Findings include: Review of the facility's policy titled, Respiratory Policy & Procedures dated 02/12/2024 revealed, Subject: Oxygen Therapy-Oxygen administration helps relieve hypoxemia and maintain adequate oxygenation of tissues and vital organs. Oxygen administration increases blood oxygen content so that the heart doesn't have to pump as much blood per minute to meet tissue demands. Indications: Hypoxemia, Heart failure . Procedures: A. Verify the provider's order for the oxygen therapy . Review of R41's Face Sheet revealed R41 was admitted to the facility on [DATE], with diagnoses including but not limited to: acute respiratory failure with hypoxia, chronic cough, nasal congestion, chronic systolic (congestive) heart failure, obesity, cardiomyopathy, essential (primary) hypertension,…

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, interviews, record review, and review of the facility's Dialysis Contract, the facility failed to ensure communication with the dialysis center for 1 of 1 resident (Resident (R)75) reviewed for dialysis. Findings include: Review of the facility's Dialysis Contract titled, Long Term Care Facility Dialysis Services Agreement, dated October 25, 2012, states under section 2B, Care facility agrees to furnish at the time of referral and request for acceptance of any Resident as a patient of Dialysis Center all appropriate medical and administrative information relating to resident condition, including without limitation the following. Resident's name, address, date of birth , and Social Security Number. Name, address, and telephone number of Resident's next of kin. Appropriate Payor information for Resident. Appropriate medical records of Resident, including the history of Resident's renal illness and record of laboratory and x-ray findings. Statement of current treatment including medications.…

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, and record review, the facility failed to ensure Certified Nursing Assistants (CNA)s and Licensed Practical Nurses (LPN)s were provided needed competency training for colostomy care and maintenance. Specifically, a CNA provided skilled nursing care to Resident (R)23's colostomy wafer that was beyond their scope of practice, for 1 of 2 residents observed for colostomy care. This failure had the potential to cause harm to R23's stoma. Findings include: Review of the Nurse Aide Candidate Skill Checklist also known as Skills Listing South Carolina Nurse Aide Candidate Handbook dated 07/01/23 reveals no competency skills or training for stoma assessment, care, and/or colostomy wafer changes. Review of R23's Face Sheet revealed R23 was admitted to the facility on [DATE], with diagnoses including but not limited to: Schizophrenia, urinary incontinence, psychotic disorder with delusions, hallucinations, Bell's Palsy, colostomy, and intellectual disabilities. Review of R23's Annual…

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, record review, interviews, and review of facility policy, the facility failed to ensure that staff used proper Personal Protective Equipment (PPE) while providing colostomy care to 1 of 8 residents, Resident (R)17. Findings include: Review of the facility policy titled, Transmission Based/Standard Precautions, and Enhanced Barrier Precautions, revised on May 15, 2023 stated, Policy: 2. Healthcare worker (HCW) will implement Universal/Standard Precautions whenever there is the occupational exposure to blood and body fluids, 4. The type of PPE (personal protective equipment) and precautions implemented depends on the potential for exposure, route of transmission, and the infectious organism/pathogen, 5. Health care workers will implement enhanced barrier precautions according to policy with additional measures to protect residents and staff from Multidrug-resistant Organisms (MDROs) MDROs refers to microorganisms predominantly bacteria that are resistant to one or more classes of…

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 review of the facility policy, record review, and interviews, the facility failed to notify the on-call provider regarding a significant change in a resident's (R)1 condition. Specifically, critical lab blood sugar readings were not communicated timely. Findings include: Review of the facility policy titled, Physician and Other Communication/Change in Condition dated [DATE], 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 patient/resident's condition, and provide guidance for the notification of patient's/residents and their responsible party regarding changes in condition. Section 3 of the policy states, 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. Changes and new approaches…

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 review of the facility policy, interview, and record review, the facility failed to ensure staff implemented interventions identified to aid in the prevention of harm with a fall for 1 (Resident (R)1) of 2 sampled residents reviewed for falls. Findings Include: Review of facility policy titled, Fall Management with a revised date of 05/05/23, revealed the facility will identify each patient/resident who is at risk for falls and will plan care and implement interventions to manage falls. Review of R1's face sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to unsteadiness on feet, muscle weakness, difficulty in walking, unspecified dementia, cognitive communication deficit and attention and concentration deficit. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/01/23, revealed R1's Brief Interview for Mental Status (BIMS) score was incomplete. It was recorded that R1 was dependent on the staff for all areas of…

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, policy review, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure 1. all staff wore the required Personal Protective Equipment (PPE) of an N95 mask, eye protection, gown, and gloves prior to entering the rooms of three of three residents (Resident (R) 133, R135, and R136) under quarantine as new admissions who were not up to date with all recommended COVID-19 vaccine doses (including booster doses, if eligible). Additionally, the facility failed to ensure a staff member with a vaccination exemption wore appropriate PPE, while in the facility. This placed all residents of the facility at an increased risk for the transmission of COVID-19. Findings include: Review of CDC guidance, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, update 02/02/22, revealed Place a patient with suspected or confirmed SARS-CoV-2 infection in a…

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 reviews, and policy review, the facility failed to assess for safe smoking for two of two residents (Residents (R) 133 and R49) reviewed for smoking in a total sample of 19 residents. This failure increases the risk of injury to residents who may have unassessed safety risk factors. Findings include: Review of the admission Packet Smoking Policy, revised 02/2022, revealed Unless otherwise noted in a separate policy, this facility is a smoke-free environment and there are NO designated smoking areas inside the building or on its premises for its residents. Smoking in any areas of the facility or on its premises, including but not limited to resident bedrooms, showers, bathrooms, activity areas, hallways or other common areas, parking lots, entrances/exits, is strictly prohibited, and will not be tolerated. All residents are prohibited from keeping any type of smoking materials (lighter, matches, cigarettes, etc) in their rooms or on their person. Violations of this policy…

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.