Marinuka Manor

Based on interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who had completed the minimum qualification requirements for the position. This practice could potentially affect all 33 residents residing in the facility. The facility does not have a director of food and nutrition services with the minimum requirements or a full time registered dietitian on site. Findings include: On 10/30/23 at 9:30 AM, Surveyor performed the initial walkthrough of the kitchen with Dietary Supervisor (DS) M. Surveyor asked DS M what qualifications they held that allowed them to assume the role of Dietary Supervisor. DS M said they had ServSafe certification, and they were working on completing a course that would qualify them as a Certified Dietary Manager. On 10/31/23 at 1:59 PM, Surveyor interviewed DS M regarding the oversight of a registered dietitian. DS M said they have a registered dietitian they work with, and they come only on Monday to complete the tasks required of a registered dietitian. The registered dietitian is…

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 record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect all 33 of 33 residents residing in the facility. Dietary Supervisor (DS) M and Dietary Aide (DA) N did not use a hair restraint over their beards while preparing, serving, and operating in the kitchen. Findings include: The facility policy, entitled Infection Control - Dress Code 2.4, not dated, states in part: A. All staff must have their hair restrained in a hairnet Men should be clean shaven or they will be required to wear a beard net. On 10/30/23 at 9:30 AM, Surveyor performed the initial walkthrough of the kitchen with DS M. The Surveyor observed that DS M had a noticeable beard approximately ½ in long protruding from behind the mask they wore. The mask did not cover all the beard, only around the mouth area. The surveyor also observed that DA N had a noticeable beard that protruded from behind the surgical mask that they wore. Both individuals had full beards that…

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 policy review, the facility failed to dispose of garbage and refuse properly. This has the potential to affect all 33 of 33 residents residing in the facility. The facility did not ensure the garbage dumpster lids were closed; this was observed multiple times during the survey. This is evidenced by: The facility policy, entitled Pest Control, not dated, states: Ongoing measures are taken to prevent, contain, and eradicate household pests such as roaches, ants, mosquitoes, flies, mice and rats All state and local regulations are followed. On 10/30/23 at 9:30 AM, Surveyor performed the initial walkthrough of the kitchen with Dietary Supervisor (DS) M. When looking at the garbage dumpsters, Surveyor observed them to be open. On 10/31/23 at 8:52 AM, Surveyor observed the large blue dumpster located outside, near the dietary employee entrance and the outdoor freezer, was open and not covered. On 10/31/23 at 1:59 PM, Surveyor observed that the large blue garbage dumpster was not covered and was open. On 11/01/23 at approximately 1:35 PM, Surveyor…

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 record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not a have a clear water management process or plan in effect to prevent transmission of Legionella infection. This has potential to effect 33 of 33 residents reviewed. Observations were made of laundry and nursing staff not performing hand hygiene with delivery of linens to residents. Registered Nurse (RN) D did not wear appropriate PPE during wound care for R4; staff did not use the proper technique by putting a barrier under R4's foot during wound care to ensure that R4 would be free from the spread of infection. Certified Nursing Assistant (CNA) C did not complete proper hand hygiene when providing personal cares to R13. Proper signage was not used for R4 who is on precautions due 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.

Based on observations and interviews, the facility did not ensure personal protection of resident medical records for 1 of 1 resident (R2). Licensed Practical Nurse (LPN) F did not ensure personal protection of R2's medical records when leaving the medication cart in the hallway unattended and the computer screen open. Findings include: The facility's policy entitled, Medication Administration, reads in part Any personal information must be hidden when not in use (cover report sheets, minimize or close computer screen). On 10/31/23 at 7:21 AM, Surveyor observed a medication cart in the 200-hallway unattended. When Surveyor walked past the medication cart the computer screen was opened. R2's information was up on the computer screen so anyone walking by could see the information. Approximately 3 - 5 minutes later, LPN F returned to the medication cart. On 11/01/23 at 8:03 AM, Surveyor interviewed Certified Nursing Assistant (CNA) and Medical Assistant (MA) G and asked what their process was when leaving medication cart. CNA/MA G indicated they lock the cart, cover up any papers with…

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 record review and interview, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 1 of 8 employees reviewed. The facility did not ensure their abuse policy was implemented when one employee's background information disclosure (BID) was last obtained on 09/17/18. Findings include: The facility policy, entitled Allegations of mistreatment/neglect/abuse/injuries of unknown source, misappropriation of resident property, exploitation, and resident to resident altercations, revised, November 2018 states in part The BID, IBIS, OIG and DOJ checks are completed every four years by the Human Resources Department. On 10/31/23, Surveyor reviewed 8 random staff Background Information Disclosures (BID) as part of the caregiver program compliance check. Surveyor was reviewing a BID for Certified Nursing Assistant (CNA) H; the form was dated 09/17/18. Surveyor reviewed the Department of Justice report that was attached, and it had the date 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 observation, interview, and record review, the facility did not provide appropriate care and treatment for 1 of 2 sampled residents (R) (R13) who were at risk for pressure injuries. R13 was observed in bed in a supine position without being repositioned and without heels being elevated for 4 hours. Findings include: The facility policy entitled, Repositioning, dated 6/2022, states in part: Staff will ensure resident is repositioned per the resident plan of care or [NAME], residents will be given pressure relieving devices for impaired or risk of impaired skin integrity. Guidelines from the National Pressure Injury Advisory Panel (NPIAP) 2016, Pressure Injury Prevention Points, accessed 02, November 2023, Prevention Points | National Pressure Ulcer Advisory Panel (npiap.com), states in part: Turn and reposition all individuals at risk for pressure injury, turn the individual into a 30-degree side lying position and use your hand to determine if the sacrum is off the bed, ensure that the heels are free…

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 record review, the facility did not ensure pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 2 residents (R) observed receiving insulin. (R4) Staff did not follow current standard of practice of priming the insulin pen prior to setting the dose to be administered to ensure the insulin pen and needle are working and the air was removed to ensure the correct amount of insulin would be administered. Findings include: Facility policy entitled, Insulin Administration stated in part, .If using an insulin pen, cleanse hub then, prime pen with 2 units .: On 10/31/23 at 7:55 AM, Surveyor observed Licensed Practical Nurse (LPN) F prepare two insulin pens (Lispro and Humulin) for administration to R4. LPN F took two insulin pens out of medication drawer and verified medication labels with medication orders on the Medication Administration Record. LPN F removed the cap from the Humulin insulin pen and wiped tip of the pen with alcohol pad. LPN F…

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.