Magnolia Crossing Nursing and Rehabilitation Cente

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan to that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 4 of 18 residents (Residents #2, #3, #13 and #22) reviewed for care plans. -The facility did not develop Resident #2's care plan related to bladder and bowel incontinence. -The facility failed to ensure that Resident #3's Comprehensive Care Plan included her diagnoses diagnosis of Alzheimer's disease, pain, Dehydration and Psychosocial wellbeing that were triggered on her admission assessment. -The facility failed to ensure Resident #13, and Resident #22 had a Comprehensive Care Plan in place for pressure ulcers/injury. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a preadmission PASSAR Level 1(PL-1) screening accurately reflected the resident's status for 1 (Resident #4) of 6 residents reviewed for PL-1 screenings. The facility failed to ensure the accuracy of the PASSAR Level 1 screening for Resident #4. The PL-1 screening for Resident #4 did not reflect the diagnosis of PTSD that was present on admission. This failure could place residents with mental illness of not receiving a PASSAR Evaluation, individualized care, or special services to meet their needs. Record review of Resident #4's face sheet dated 7/16/2026 revealed a [AGE] year-old female originally on 7/12/2025 and readmitted on [DATE]. Resident #4 had a diagnosis of PTSD (a mental health condition that's caused by an extremely stressful or terrifying event either being part of it or witnessing it). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to review and revise the comprehensive care plan by the interdisciplinary team after assessment or change of condition for 2 of 21 residents reviewed for care plan revision (Residents #7, #42). Resident # 7's fall on 3/21/26 was not documented in the comprehensive care plan. Resident # 42's fall on 4/6/26 was not documented in the comprehensive care plan. These failures placed residents at risk of not receiving proper care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 2 residents (Resident #13 and #22) observed for pressure ulcer/injury treatment. LVN A failed to ensure wound care was provided in accordance with accepted standards of nursing practice by failing to use aseptic wound cleansing technique, including using separate clean gauze for cleansing the wound bed and the peri wound during pressure ulcer/injury treatment. This failure could place residents at risk for contamination, infection, delayed wound healing, and further decrease in quality of life.

Inspectors wrotePurpose for Visit: Complaint and Incident Investigations. Entrance date: 4/22/2026Census: 102Intakes:2988707297733729832282975728298799829764842989108 Abbreviations:ADM: AdministratorCMA: Certified Medication AideDON: Director of NursingG-tube: GastrostomyHCI: HydrochlorideMCG: microgramMg: milligramsNP: Nurse Practitioner Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys to meet the needs for 1 out of 2 medication (Medication Cart #1) carts reviewed for pharmacy service in that: The facility failed to ensure CMA B did not leave medications on top of the mediation cart. This failure could place residents at risk of not receiving their medications, choking and respiratory distress. [...]

Inspectors wroteBased on interviews and record review, the facility failed to incorporate recommendations from PASSR evaluation report into a resident's assessment, care planning and transition of care for 1 (Resident#1) of 1 residents reviewed for PASSR services. The facility failed to submit the NFSS form in a timely manner to coordinate with the PASRR unit. This failure could place residents who were PASRR positive at risk of not getting the PASARR services for a better quality of life and could lead to a decline in health. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #1) of five residents reviewed for nursing services received adequate supervision and assistive devices to prevent accidents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (CR #1) of 5 residents reviewed for quality of care. The facility failed to perform an assessment on CR #1 when she reported to have trouble breathing. This failure could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition and/or the need for hospitalization and prolonged treatment.

Inspectors wroteBased on interview and record reviewed, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 (Resident #1) of 4 residents reviewed for implementing abuse policy. -The facility failed to implement their abuse policy and procedures when Nurse A did not report to the Administrator that Resident #1's family member reported to Nurse A on 08/16/25 that CNA A allegedly hit Resident #1 on his right eye, on an unknown date. This failure could place residents at risk for abuse to go undetected, to continue due to lack of identification, investigation, and reporting in accordance with policy, serious psychological and physical harm, and injury.

Inspectors wroteBased on interview and record reviewed, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #1) of 4 residents reviewed for reporting of alleged allegations. - The facility failed to ensure Nurse A reported to the facility Administrator when Resident #1's family member's reported an alleged abuse allegation. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to assess the resident for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 3 of 6 Residents (Resident #95, Resident #64, and Resident #356,) reviewed for the use of side rails. The facility failed to ensure nursing staff obtained physician orders and consent for the use of side rails for Residents #95, #64 and #356. This failure could place residents at risk of injury, hinder residents from getting out of bed, and/or cause a decline in resident's ability to engage in activities of daily living.

Inspectors wroteBased on interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each residents individuality for 2 of 8 resident (Resident #36 and Resident #86) reviewed for resident rights. 1. The facility failed to ensure CNA G treated Resident #36 with respect and dignity when CNA G left Resident #36 without a brief and exposed while in the hallway after leaving her room. 2. The facility failed to ensure LVN R and CNA M treated Resident #86 with respect and dignity when LVN R and CNA M made the resident get out of bed and take a shower after she refused. These failures could place residents at risk for a diminished quality of life, loss of dignity, and self-worth.

Inspectors wroteBased on interview, and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for 1 of 6 residents (Resident #36) reviewed for dental services. The facility failed to ensure Resident #36 was referred to the dentist after she complained of tooth pain. This failure could place residents at risk of pain and decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to 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 infection for 2 of 10 residents (Resident #36 and Resident #86) reviewed for infection control. 1. The facility failed to ensure CNA G followed appropriate infection control and hand hygiene procedure when providing care to Resident #36 and Resident #86 2. LVN U failed to follow appropriate Enhanced Barrier Precautions; and, failed to wash or sanitize her hands prior to, and after providing incontinent care to Resident #86. These failures could place the residents at risk for infection and cross-contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, clean and homelike environment for 1 of 8 (Resident #1) residents reviewed for resident rights in that: 1. Resident #1's linen had not been changed in 8 days, had dried fecal matter and food crumbs. This failure could have caused skin breakdown, infections and dignity issues. Findings Included: Observation on 5/7/2025 at 12:04pm, revealed Resident #1 linen was dirty due to dry fecal matter, and food crumbs. Record review of Resident #1's face sheet dated 5/7/2025 revealed he was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses of unspecified dementia, functional quadriplegic, pain in right and left shoulders, muscle wasting and atrophy and need for assistance with personal care. Record review of Resident #1's MDS dated [DATE] revealed C0500: [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 8 residents (Resident #2) reviewed for Activities of Daily Living. -The facility failed to ensure Resident #2 received her bed baths on Tuesdays, Thursdays, and Saturdays on the morning shift as scheduled. This failure could have caused residents skin breakdown, discomfort, and embarrassment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 9 residents (Resident #1) reviewed for accidents and supervision. CNA A fell asleep while feeding Resident #1 lunch on 04/18/2025 and did not wake up to evaluate Resident #1 after she began to cough. This failure placed residents who required feeding assistance at risk of aspirating food particles, pneumonia (an infection that inflames air sacs in one or both lungs), and possible death.

Inspectors wroteBased on interview and record review the facility failed to incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for 4 of 4 resident's (Resident #1, #2, #3, #4) reviewed for PASRR. -The facility failed to submit authorization of PASRR Habilitative Services for Resident#1, #2, #3, #4. This failure could place residents identified at a level II for PASRR evaluation at risk for their specialized services not being provided in a timely manner.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure allegations of abuse, neglect or mistreatment, including injuries of unknown origin was reported immediately, but not later than 2 hours after the allegation is made for 1 (CR#1) out of 4 residents reviewed for reporting alleged abuse and neglect. -The facility failed to report CR#1's right hip fracture that was discovered on 10/27/2023 to the state agency. This failure could place residents at risk for not having incidents reported as required and continued abuse and neglect which could result in diminished quality of life.