Magnolia Springs Loveland

Based on record review ,interview, and facilities policy review, the facility failed to document in the medical record and notify the resident family representative of a significant change in the clinical condition of a resident. This affected one resident, (Resident #104) of three residents reviewed for change in clinical condition. The facility census was 120.

Findings included:

Record review of Resident #104 revealed the resident was admitted to the facility on 08/26/21. Diagnoses for Resident #104 include dementia, diabetes, anxiety disorder osteoporosis, chronic obstructive pulmonary disease, and hypertension.

Review of the Functional Assessment comprehensive assessment and Service Plan dated 10/24/23 revealed the resident had severely impaired cognition and required moderate assistance with mobility, and transfers. The resident fed herself with cueing required from the staff. The resident resided on the Memory Care unit and received hospice care services. The resident required no extensive nursing services.

Review of nursing notes dated 01/09/24 at 5:57 P.M.,revealed Nurse Practitioner, (NP) #300 had visited the resident and ordered new lab testing, buspirone 5 milligrams, (MG) daily as needed and increased sertraline to 50 mg daily. There were no notes notifying the family representative of the changes in medication and or notification of a change in condition. From 01/09/24 through 02/18/24, lab values results were received, without notification to the family representative. On 02/19/24, the NP #300 ordered a chest x-ray. Nursing notes from 02/09/24 through 02/29/24 revealed no notification to the family representative of the chest x-ray result.

Interview on 03/06/24 at 1:32 P.M. with the Memory Care Wellness Director, (MCWD) verified Resident #104 nursing notes of 01/09/24 did not have documentation of the family representative notification of the new lab and medication changes ordered by NP #300. MCWD verified the nursing notes of 02/19/24 through 02/29/24 did not have documentation the family representative was notified of the chest x-ray results. MCWD verified the nurse should have notified the family representative of Resident #104 new orders, results of orders and/or the condition changes of the of 01/09/24 and 02/19/24.

Interview on 03/06/24 at 3:51 P.M., with the Executive Director verified the NP #300 had not been in communication with the facility regarding outside conversations with the family representative and there was no documentation in the nursing notes that Resident #104's family representative had been notified of medication changes, lab results and x-ray results of 01/09/24 and 02/19/24.

Review of facility policy titled Change of Resident Status, dated 08/11/21, revealed notification will be made to the resident's legal authority and/or responsible party regarding changes in resident status. All information regarding resident change in status will be documented in the resident's medical record.

This violation represents non-compliance investigated under Complaint Number OH00151739.

Based on observation, interview and record review, the facility failed to prevent food contamination when food was served from the kitchen and kitchenettes. This had the potential affect all 120 residents served food from the kitchen and kitchenettes. The total facility census was 120.

Findings include:

Review of the resident listing of diet orders, all 120 residents who resided in the facility received food from the kitchen and/or the three kitchenettes located in the Memory Care.

Observations on 03/05/24 at the breakfast meal and at the lunch meal revealed Care Givers, (CG) # 24, #53 and #100 were serving foods from uncovered food steamtable onto resident plates with no hair covering. The CG #24, #53 and #100 had unstrained hair over open food for the entire food service of breakfast and lunch.

Observation on 03/05/24 at 3:40 P.M. during dinner meal service preparation, Assistant Chef #19 was preparing foods and working on the food service line with uncovered foods. Assistant Chef #19 had no facial covering of a exposed beard. Resident Dining Room Food Server #81 was observed to obtain ice from the open bin ice machine, located in the food preparation area, with no hair covering. The Dietary Manager, (DM) # 74 was in the food preparation area during the observation.

Interview on 03/05/24 during breakfast meal service, from 8:45 A.M. to 8:59 A.M. and during lunch meal service from 12:07 P.M. to 12:27 P.M., CG #24, #53 and #100 verified they had not worn hairnets during the meal service because they did not know it was required and /or the hairnets were not available.

Interview on 03/05/24 at 3:43 P.M., DM #74 verified the food in the kitchen was prepared for all residents in the facility. The food was sent to the Memory Care unit in bulk from and served from the Memory Care kitchenettes by the Care Givers. The DM #74 verified CG #24, #53 and #100 had not worn hair restraints while serving food on the Memory Care unit, as it had not been required. DM #74 verified Assistant Chef 19 did not have a facial covering when preparing foods and working with uncovered foods on the steam table. DM #74 verified Dining Room Server #81 was in the food preparation area to obtain ice without hair covering. DM #74 verified hair and facial hair should be covered when working in food preparation areas.

Review of the facility Sanitation and Infection Control Manuel, section titled, Employees Personal Cleanliness, dated 2015, revealed hairnet or caps should always be worn in food preparation areas and during food preparation.

This violation is an incidental finding investigated under Complaint Number OH00151311 and Complaint Number OH00151739.