Magnolia Gardens Center for Nursing and Rehabilita

Inspectors wroteBased on record reviews and staff interviews, the facility failed to provide Registered Nurse (RN) coverage at least 8 consecutive hours per day, 7 days per week for 13 out of 36 days reviewed for staffing (4/27/25, 5/4/25, 5/25/25, 6/1/25, 6/15/25, 6/22/25, 8/23/25, 8/31/25, 9/6/25, 9/7/25, 9/14/25, 9/20/25, and 9/21/25).

Inspectors wroteBased on record reviews and staff interviews, the facility failed to revise the care plan for 1 of 2 sampled residents reviewed for advance directive status (Resident #46).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure a resident had a physician's order to receive hospice services for 1 of 1 resident reviewed for hospice (Resident #3).

Inspectors wroteBased on observation, record review, and interviews with facility staff, resident, and the Contracted Van Transportation Company Owner, the facility failed to ensure Resident #1's wheelchair was secure on the contract transportation van lift by the Contract Van Driver before the lift platform was raised to the elevated position. On 3/7/25, Resident #1 was loaded onto the van lift by the Contract Van Driver. The lift was positioned at the rear entrance of the van and Resident #1 was facing out away from the van. When the lift platform was at the floor level of the van, Resident #1's wheelchair rolled forward, away from the van, and Resident #1 fell forward, off of the lift, landing on the asphalt parking lot. Resident #1 fell approximately 48 inches from the raised lift platform onto the ground. [...]

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to ensure staff implemented their abuse policy and procedure in the area of reporting when facility staff had knowledge of an allegation of sexual abuse. This failure resulted in a delay in the facility initiating a thorough investigation of the allegation, implementing protective measures, and reporting the allegation to the State Agency, Law Enforcement and Adult Protective Services. This deficient practice was found for 1 of 3 residents reviewed for abuse (Resident #1).

Inspectors wroteBased on record review and interviews of staff, the resident, and the nurse practitioner, the facility failed to correctly transcribe the resident's (Resident #57) nephrology order for sterile saline flush 15 to 30 milliliters of the suprapubic urinary catheter every 12 hours. The resident's order was put in as a one-time order and only one sterile saline flush was completed. This deficient practice affected 1 of 3 residents reviewed for urinary catheter.

Inspectors wroteBased on record review, observations, resident, and staff interviews the facility failed to provide care in a manner to maintain the resident ' s dignity by not answering call bells for residents that need extensive assistance with activities of daily living (ADLs). This was evident for 3 of 6 residents (Resident #10, Resident #3, and Resident #4) reviewed for dignity.

Inspectors wroteBased on record review, resident, and staff interviews, the facility failed to communicate the facility's efforts to address group concerns verbalized during Resident Council meetings and to resolve repeat concerns for 8 of 9 consecutive months (September 2023, October 2023, November 2023, December 2023, January 2024, February 2024, March 2024, and April 2024).

Inspectors wroteBased on observations, record review, and staff interview the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation surveys completed on 09/01/22 and 07/20/23. This was for 2 deficiencies that were cited in the areas of Resident Rights/Exercise of Rights and Reasonable Accommodation of Needs/Preferences. Resident Rights/Exercise of Rights was cited on the recertification and complaint survey on 09/01/22 and recited on the current complaint survey of 05/09/24. Reasonable Accommodation of Needs/Preferences was cited on 07/20/23 and recited on the current complaint survey of 05/09/24. [...]

Inspectors wroteBased on observation, record review, resident interviews, and staff interviews, the facility failed to place a resident's call light (Resident #5 and #7) within reach to allow for the residents to request staff assistance this was for 2 of 3 residents reviewed for accommodation of needs.

Inspectors wroteBased on record review and staff interviews, the facility's administration failed to investigate and complete a root cause analysis for a fall for 1 of 4 residents reviewed for accidents. (Resident #8). The deficient practice led to the inability to implement effective interventions to prevent a reoccurrence.

Inspectors wroteBased on observation, record review, and interviews of staff and a resident, the facility failed to provide a dependent resident a wheelchair to accommodate her size and inability to sit up. The resident was unable to get out of bed unless the staff would borrow a wheelchair from another resident with the same accommodation needs (Resident #93) for 1 of 2 residents reviewed for accommodation of needs.

Inspectors wroteBased on staff interviews and medical record review, the facility failed to provide a CMS-10055 (Centers for Medicare and Medicaid Services) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) prior to discharge from Medicare part A services to 2 of 3 residents (Resident #36 and Resident # 29) reviewed for SNF Beneficiary Protection Notification Review.

Inspectors wroteBased on observations, and resident and staff interviews, the facility failed to repair the walls in the resident's room after under-sink cabinets were removed leaving holes in the wall and no floor tile in two residents rooms (rooms [ROOM NUMBERS]) and failed to maintain the wall behind a bed in good repair (room [ROOM NUMBER]). The deficient practice was observed on 1 of 2 halls (200 hall).

Inspectors wroteBased on staff interviews and medical record review, the facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days after the facility determined a significant change occurred for 1 of 4 residents (Resident #59) reviewed for significant change MDS assessments.

Inspectors wroteBased on observation, staff interviews and record review, the facility failed to develop a care plan that addressed the use of a urinary catheter for 1 of 3 residents (Resident #59) reviewed for urinary catheters.

Inspectors wroteBased on observations, resident and staff interviews and medical record review, the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection or injury for 1 of 3 residents (Resident #59) reviewed for indwelling urinary catheters.

Inspectors wroteBased on observation, record reviews, and staff interviews the facility failed have a physician order for a therapeutic diet per the Speech Therapist's evaluation for 1 of 5 residents (Resident #71) reviewed for nutrition.

Inspectors wroteBased on observations, record review, and staff interview the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification surveys completed on 9/1/22 and 4/22/21. This was for 4 deficiencies that were cited in the areas of Safe/Clean/Comfortable/Homelike Environment (F584), Comprehensive Assessment After Significant Change (F637) which were cited on 9/1/22 and recited on the current recertification and complaint survey 7/20/23. Develop/Implement Comprehensive Care Plan (F656) which was cited on 9/1/22, 4/22/21 and recited on the current recertification and complaint survey 7/20/23. Bowel/Bladder Incontinence, Catheter, UTI (F690) cited on 4/22/21 and recited on the current recertification and complaint survey 7/20/23. [...]