Magnolia Manor

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 8 residents (Resident #1) reviewed for pharmacy services. The facility failed to accurately reconcile and transcribe Resident #1's hospital discharge medication on facility admission which resulted in Resident #1 not receiving 66 doses of levothyroxine (thyroid) medication. The facility failed to complete a secondary reconciliation of Resident #1's admission orders from the hospital to ensure all orders were transcribed, ordered, and administered. The facility failed to review and complete the pharmacy recommendation of clarifying Resident #1's order for levothyroxine. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents had the right to retain and use personal possessions, including clothing, as space permits, unless to do so would infringe upon the rights of others for 1 of 3 residents (Resident #1) reviewed for respect and dignity. The facility failed to inventory and label Resident #1's clothing at admission and before her clothes were sent to the facility's laundry room. This failure could place residents at risk of their clothing not being returned, lost, stolen, and not having adequate clothing options.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store, prepare, distribute, and serve food in accordance with the professional standards for food service safety 1 of 1 kitchen reviewed for safety requirements. 1. The facility failed to ensure foods were sealed and/or labeled properly in freezer and dry storage. 2. The facility failed to ensure food items in the dry pantry were labeled, dated, sealed, and not expired. 3. The facility failed to ensure dented cans in the dry pantry were not stored and co-mingled with non-dented food cans ready for use. These failures could place residents, who received food and beverages from the kitchen, at risk for health complications, foodborne illnesses, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the assessments accurately reflected the resident's status for 2 of 20 residents reviewed for accuracy of assessments. (Residents #73 and #86) 1. The facility failed to ensure Resident #73's most recent quarterly assessment captured the resident's range of motion (ROM) limitations to her left lower extremity. 2. The facility failed to ensure Resident # 86's most recent quarterly assessment captured the resident's range of motion limitations to her right lower extremity. These failures could place the residents at risk for not receiving the appropriate care and services.

Inspectors wroteBased on observation and interview, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for 1 of 13 residents (Resident #244) reviewed for new admissions. The facility to develop and accurately complete a baseline care plan within 48 hours of admission for Resident #244. This failure could lead to residents not receiving necessary care and decreased quality of life. Record review of Resident #244's face sheet, dated 07/02/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 20 residents reviewed for care plans. (Residents #45 & #86) 1. The facility did not have a care plan to address Resident #45's Risperidone (antipsychotic medication). 2. The facility did not have a care plan to address Resident #86's contractures (a structural change in the body's soft tissues, like muscles, tendons, ligaments, or skin, that causes them to stiffen and shorten causing limited range of motion (ROM) and pain in the affected areas) Resident's right lower extremity. These failures could place residents at risk of not having their individual needs met and not receiving needed services.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (is a medication used: without adequate indication for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued) for 2 of 5 residents (Residents #45 and #77) reviewed for unnecessary medications. 1. The facility failed to ensure Resident #45 had an appropriate diagnosis entered for order for his Risperidone (antipsychotic) and Divalproex (an anticonvulsant used to treat seizures, migraine, and bipolar disorder). 2. The facility failed to ensure Resident #77 had an appropriate monitoring for his Oxcarbazepine (anticonvulsant used to treat depression). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessments accurately reflected the resident's status for 1 of 20 residents reviewed for accuracy of assessments. (Resident #244)The facility failed to ensure Resident #244's Nursing admission Assessment was complete and accurately reflected the resident's status at the time of the assessment. This failure could place the resident at risk of not receiving the appropriate care and services. Record review of Resident #244's face sheet, dated 07/02/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included chronic gout (characterized by repeated episodes of joint pain and inflammation due to uric acid in the blood), emphysema (chronic lung disease that progressively damages the tiny air sacs in the lung, making it difficult to breathe), and adjustment disorder with anxiety. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the written abuse policy to ensure an allegation of sexual abuse was reported immediately to the Abuse Coordinator, State Agency, and implement measures to ensure residents were protected from further abuse after an allegation of abuse for 1 of 20 residents (Resident #10) reviewed for allegations of abuse. 1. The facility failed to ensure CNA K was suspended/terminated or removed from working with all residents after a sexual abuse allegation was reported on 01/11/2025. 2. The facility failed to immediately report the sexual abuse allegation to the Abuse Coordinator. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 01/11/2025 and ended on 01/18/2025. The facility had corrected the non-compliance before the survey began. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure allegations of abuse to the abuse coordinator, allegations of abuse were reported to the state agency within the required 2 hour timeframe, and allegations of misappropriation were reported to the state agency within the required 24 hour timeframe for 6 of 20 residents reviewed for freedom from abuse, neglect, and exploitation/ misappropriation. (Residents #1, #2, #3, #4, #5, and #10) 1. The facility failed to report a sexual abuse allegation immediately to the Abuse Coordinator. LPC J and LVN E did not immediately report, to the Abuse Coordinator, when Resident #10 reported a sexual abuse allegation on CNA K. This non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 01/11/2025 and ended on 01/18/2025. The facility had corrected the non-compliance before the survey began. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 (Resident #7) residents reviewed for pain. The facility failed to administer Resident #7 pain medication for a complaint of pain intensity level of 10 (worst pain possible) out of 10 on [DATE] and pain intensity level of 8 (severe pain) out of 10 on [DATE] due to facility did not have Resdient #7's ordered pain medication available. This failure could place residents at risk for increased pain and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to consult with the resident's physician when there was a need to alter treatment for 1 of 5 residents (Resident #7) reviewed for physician notification with changes in condition. 1. The facility failed to notify the physician of Resident #7 not having pain medications available at the facility when he was admitted on [DATE] with diagnoses of pain and orders for oxycodone for pain. 2. The facility failed to notify Resident #7's physician on [DATE] when he had a change in condition with unmanageable pain when he complained of excruciating pain (scaled 10 out of 10). The facility failed to notify Resident #7's physician on [DATE] when he had break through pain, scale of 8 out of 10, after returning from the hospital with a fentanyl patch. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that licensed nursing staff were able to demonstrate the specific competencies and skill sets pain assessments, pain management, accessing CMEK, notifying physician of change in condition and arranging urgently needed medication order and delivery from pharmacy. The facility failed to ensure LVN II was competent in pain assessments, pain management, accessing CMEK, notifying physician of change in condition and both LVN II and UM/LVN H were competent in arranging urgently needed medication order and the delivery from pharmacy for 2 of 8 residents (Resident #7 and Resident #8) assessed for staff competency. The failure could place residents at risk for prolonged and unnecessary pain and suffering and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 2 of 2 residents (Resident #6 and Resident #7) reviewed for controlled medications. 1. Resident #6's hydrocodone 7.5 mg /acetaminophen 325 mg (narcotic pain medication for moderate or severe pain) were not accounted for at the time of discharge 08/11/24 and remained unaccounted for after his discharge. 2. The facility did not have pain medication for Resident #7 for a complaint of pain intensity level of 10 (worst pain possible) out of 10 on 09/15/2024 and pain intensity level of 8 (severe pain) out of 10 on 9/15/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 stove in the kitchen reviewed for essential equipment. The facility did not ensure the gas stove was in safe operating condition. Three burners on the back of the stove and the 2 ovens would not ignite when the knobs were turned. This failure could place the residents at risk of a fire and not having safe operating equipment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to be treated with respect and dignity including the right to retain and use personal possessions including furnishings, and clothing, as space permitted, unless to do so would infringe upon the right or health and safety of other residents for 4 (Residents #9, #13, #47, and #268) of 18 residents reviewed for the right to retain and use personal possessions. The facility failed to return all their personal clothes from the laundry for Residents #9,#13, #47 and #268 from 04/17/24 to 04/22/24. This failure could place residents at risk of having their rights infringed upon and could lead to the residents not being able to use their personal clothes. Findings Included: 1. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the right to formulate an advance directive was provided for 2 of 6 residents reviewed for resident rights. (Resident #27 and #62) * The facility did not have a valid Out of Hospital-Do Not Resuscitate (OOH-DNR) for Residents #27 and #62. This failure could place residents at risk of lifesaving procedures being performed against their wishes resulting in bruising, broken ribs, electrical shocking of the heart, having a tube placed in the throat and provided artificial breathing methods, and possibly being brought back to life in an unaware and unresponsive state.

Inspectors wroteBased on interview and record review, the facility failed to provide services as outlined by the comprehensive care plan, to meet professional standards of quality for consultation with the resident's physician when there was a significant change in the resident's condition or a need to alter treatment significantly for one (Resident #39) of 18 residents reviewed for following physician's orders. The facility failed to implement Resident #39's care plan when his blood pressure and/or heart rate fell below prescribed parameters and did not notify his physician in April 2024. (04/03/24, 04/08/24, 04/11/24, 04/12/24, 04/13/24, 04/20/24, 04/21/24, 04/22/24, and 04/23/24). The failure placed residents, who required blood pressure and heart rate monitoring, at risk for complications due to delayed physician intervention.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported, but not later than 2 hours after the allegation is made, if the events that cause the allegation involves abuse or result in serious bodily injury, to the State Survey Agency, for 1 (Resident #2) of 16 residents reviewed for reporting allegations of abuse. The facility failed to report an allegation of physical abuse within 2 hours to the State Agency when Resident #2 reported to facility staff that Resident #1 hit/slapped her in the head. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteThe facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 18 residents reviewed for respiratory care. (Resident #29) The facility failed to follow physician orders for Resident #29's oxygen. This failure could place the residents at risk of not receiving the care and services to maintain their highest level of well-being.

Inspectors wroteBased on interview and record review, the facility failed to maintain the daily nurse staffing data for at least 18 months of last 18 months. The facility to ensure the records for the posted daily nurse staffing data were maintained from October 2022 to April 23,2024. This failure could place residents, families and visitors at risk of not being able to request the daily nurse staffing data record for the last 18 months.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was allowed to remain in the facility and not transfer or discharge unless they met a requirement for discharge 1 of 1 resident (Resident #2) reviewed for discharge rights. * The facility discharged Resident #2 without indicating the discharge was necessary for the resident's welfare, what needs of the resident the facility could not meet; the resident's health had improved sufficiently so the resident no longer needed the services provided by the facility; the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; the health of individuals in the facility would otherwise be endangered; or resident had failed, after reasonable and appropriate notice, to pay for a stay at the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure recommendations from PASARR evaluation were incorporated for 1 of 1 resident reviewed for coordination of PASARR services. (Resident #1) Facility failed to provide specialized services for PASARR positive residents as agreed to during Resident #1's meeting by the required timeframe. This failure could place the residents with intellectual and developmental disabilities at risk of not receiving specialized services that would enhance their highest level of functioning.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good personal hygiene for 2 of 18 residents reviewed for ADL care. (Resident #'s 29 and 40) *The facility failed to maintain Resident #29's fingernails, which extended ¾ inch past the tips of each finger; and had brown substance caked under nails. *The facility failed to maintain Resident #40's fingernails, which extended approximately ¾ inch past the tips of each finger. The 4th digit (ring finger) and 5th digit (pinky finger) fingernails of the resident's right contracted hand caused indentations in the palm of the resident's right hand. This failure could place the residents at risk for not receiving the care and services to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 18 residents reviewed for range of motion. (Resident #40) The facility failed to maintain Resident #40's contractures of the right hand. The resident did not have a handroll in place to maintain ROM and prevent a decline. This failure could place the residents at risk for not receiving the care and services to maintain their highest level of well-being.