Magnolia Lane Nursing and Rehabilitation Center

Inspectors wroteBased on record review, and resident and staff interviews, the facility failed to communicate the facility's efforts to address concerns and document in writing the facility's response and rationale to concerns voiced during Resident Council meetings for 5 of 10 Resident Council meetings reviewed (January 2025, March 2025, June 2025, July 2025, and August 2025).

Inspectors wroteBased on record review and staff interviews, the facility failed to submit a request for an evaluation for a Level II Preadmission Screening and Resident Review (PASRR) determination for residents who were admitted to the facility with serious mental health disorders for 4 of 4 residents reviewed for PASRR (Resident #37, Resident #7, Resident #52 and Resident #50).

Inspectors wroteBased on observations and staff interviews, the facility failed to discard food past its use-by date in 1 of 1 walk-in cooler and store food off the floor in 1 of 1 walk-in freezer. These practices had the potential to affect food served to residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the Do Not Resuscitate (DNR) form was signed by the physician and part of the medical record after the physician ordered for the resident to be Do Not Resuscitate for 1 of 21 residents reviewed for advanced directives (Resident #2).

Inspectors wroteBased on record review and staff interviews, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN, a form used by skilled nursing facilities to inform residents about potential costs and coverage limitations for services that may not be covered by Medicare) to beneficiaries who intended to continue services and the SNF believed the services may not be covered under Medicare prior to discharge from Medicare Part A skilled services for 3 of 3 residents reviewed for beneficiary notification review (Residents #6, #16, and #76).

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to ensure a qualified staff member with the necessary skills and licensure inserted a peripheral intravenous (IV) catheter when a Medication Aide used the needle from an IV catheter kit and inserted it into a resident's arm (Resident #78). The deficient practice was identified for 1 of 5 nursing staff reviewed for sufficient and competent nurse staffing (Medication Aide #1).

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to maintain oral hygiene for a dependent resident unable to brush their teeth for 1 of 3 residents reviewed for activities of daily living (Resident #31).

Inspectors wroteBased on record review and interviews with the Pharmacy Operation Manager and staff, the facility failed to have effective systems in place for the return of controlled medications to the pharmacy for 3 of 3 residents (Resident #15, Resident #25 and Resident #79).

Inspectors wroteBased on record review, observation, and interviews with the Registered Dietitian (RD) and staff, the facility failed to follow the physician's diet order for double portions at breakfast and the enriched meal program for 1 of 5 residents reviewed for nutrition (Resident #52).

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to implement their infection control policy and procedures for Enhanced Barrier Precautions (EBP) when Nurse #2 did not put on a protective gown prior to a high contact care activity that involved administering a nutritional supplement and water flushes through a resident's (Resident #45) feeding tube (a medical device inserted into the stomach). This occurred for 1 of 5 staff members reviewed for infection control practices (Nurse #2).

Inspectors wroteBased on record review and interviews with resident, staff, Medical Director (MD) and Pharmacy staff, the facility failed to have effective systems in place for acquiring and maintaining the supply of medications in the controlled medication emergency kit which resulted in an as needed pain medication not being available for Resident #1 when he was admitted to the facility. This deficient practice occurred for 1 of 3 residents reviewed for pharmacy services (Resident #1).

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to dry insulated bases, lids, pans and baking sheets before they were stacked for use, failed to store perishable food off the floor, failed to remove a dented canned good item stored for use, and failed to discard expired food and food items with signs of spoilage stored in 1 of 1 walk-in cooler and main dining room refrigerator. In addition, the facility failed to cover facial hair during food preparations. These practices had the potential to affect food served to residents.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain the grounds surrounding one of two trash dumpsters free of broken equipment and to keep the grease trap surrounding area clean and free from debris. These failures had the potential to impact sanitary conditions and to attract pests and rodents.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain the privacy of a resident's record by leaving a medication cart laptop unattended with resident health information exposed in an area accessible and visible to the public on 1 of 2 medication carts (medication cart #1).

Inspectors wroteBased on observations, record reviews, resident, staff, Pharmacy Consultant and Medical Director (MD) interviews, the facility failed to protect the resident's rights to be free from misappropriation of controlled substance for 1 of 1 resident reviewed for misappropriation of resident property (Resident #43).

Inspectors wroteBased on observation, staff and resident interviews, and record review, the facility failed to provide assistance with oral care for 1 of 2 dependent residents (Resident #30) reviewed for activities of daily living (ADL).

Inspectors wroteBased on observations and staff interviews, the facility failed to label tube feeding formula with the date and time the formula was hung and flow rate for 1 of 1 resident reviewed for tube feeding (Resident #26).

Inspectors wroteBased on observations, record review, and staff, facility Corporate Dietitian, Dialysis Center Registered Dietitian, and Medical Director interviews the facility failed to obtain a physician order for the resident to receive dialysis, monitoring of the dialysis access site, and fluid restrictions for 1 of 1 resident reviewed for dialysis (Resident #4).

Inspectors wroteBased on observations, record review, and resident and staff interviews, the facility failed to determine a resident's food preferences and failed to offer an alternative option. This occurred for 1 of 1 resident reviewed for choices (Resident #23).

Inspectors wroteBased on observations and staff interviews, the facility failed to post a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, the home and community based service programs, and the Medicaid Fraud Control Unit. This observation occurred for 3 of the 4 days during the onsite recertification survey.

Inspectors wroteBased on observations, resident council and staff interviews, the facility failed to post signage about the availability of the most recent survey results for three (3) of four (4) days during the recertification survey. This had the potential to affect all residents residing in the building.

Inspectors wroteBased on record review and staff interviews, the facility failed to post accurate Registered Nurse (RN) staffing information for 8 days of the 205 days reviewed for daily posted staffing (3/22/24, 4/10/24, 4/12/24, 4/22/24, 5/13/24,7/20/24, 8/17/24, 8/31/24).

Inspectors wroteBased on record review and staff, resident, and Medical Director interviews the facility failed to assist a resident with a transfer from the wheelchair to bed when Nurse Aide (NA) #1 stood behind Resident #4 and allowed the resident to transfer independently. Resident #4's leg slipped, the resident fell onto the bed and experienced shoulder pain. Resident #4 sustained a left humeral head fracture of the shoulder as was noted on the CT (computed tomography) scan on 7/20/2023. This was for 1 of 3 residents reviewed for supervision to prevent accidents.