Magnolia Manor - Inman

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure the residents' code status preference was honored in that the physician's order did not match the code status preference on the residents' Physician Order for Life Sustaining Treatment (POLST) document for two (Resident (R)9 and R77) of five residents reviewed for code status. This failure had the potential to result in the residents not receiving lifesaving cardiopulmonary resuscitation (CPR).

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to report blood sugar levels (BS) below 60 mg/dl (milligrams per deciliter) to the physician and failed to follow physician orders to hold insulin when the BS was below 100 mg/dl for one (Resident (R)87) of one resident reviewed for laboratory services.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure the physician documented that the Clinical Pharmacist (CPh) recommendations regarding the use of a PRN (as needed) medications were reviewed and failed to document the action taken or not taken to address the irregularities for one (Resident (R)13) of five residents reviewed from a sample of 43 residents. This failure had the potential to lead to unwarranted medication side effects or improperly treated symptoms.

Inspectors wroteBased on review of facility policy, interview and record review, the facility failed to ensure that Resident (R)1 was provided appropriate supervision to prevent 2 separate elopements from the facility on 04/28/25. On 06/03/25 at 5:53 PM, the Administrator and the Director of Nursing were notified that the failure to ensure that Resident (R)1 was free from two separate elopement incidents from the facility on 04/28/25, constituted Immediate Jeopardy (IJ) at F689. On 06/03/25 at 5:53 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility that IJ existed as of 04/28/25. The IJ was related to 42 CFR 483.25 - Quality of Care. On 06/04/25 at 11:54 AM, the facility provided an acceptable IJ Removal Plan. On 06/04/25 at 12:28 PM, the survey team validated the facility's corrective actions and removed the IJ. [...]

Inspectors wroteBased on review of the facility policy, record review, and interview, the facility failed to report an allegation of elopement that occurred on 04/28/25. Specifically, Resident (R)1 eloped two separate times from the facility on 04/28/25 and the facility failed to report the elopement.

Inspectors wroteBased on review of the facility's policy, record review, and interview, the facility failed to provide documentation to that a proper investigation was conducted regarding an incident that occurred on 04/12/2025 involving an allegation of staff-to-resident abuse concerning Resident (R2).

Inspectors wroteBased on review of facility policy, record review, and interview, the facility failed to ensure Resident (R)4 was free of accidents for 1 of 4 residents review for accident hazards.

Inspectors wroteBased on review of facility policy, observation, record review, and interview, the facility failed to protect Resident (R)1 from misappropriation of more than $600.00 from her personal bank account, for 1 of 1 residents reviewed for misappropriation.

Inspectors wroteBased on review of facility policy, record review, and interviews, the facility failed to protect Resident (R)11 from neglect, by failing to administer (R)11's physician ordered antibiotics, resulting in loss of limb. On 12/19/24 at 10:10 AM, the Administrator was notified that the failure to administer physician ordered antibiotics as treatment for a Pressure Ulcer (PU)/Pressure Injury (PI), constituted IJ at F600. On 12/19/24 at 10:10 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 11/21/24. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation. On 12/19/24, the facility provided an acceptable IJ Removal Plan. On 12/19/24, the survey team, validated the facility's corrective actions and removed the IJ. [...]

Inspectors wroteBased on review of facility policy, record review and interviews, the facility failed to provide treatment, consistent with professional standards of practice for Resident (R)11's Pressure Ulcer (PU)/Pressure Injury (PI). Specifically, the facility failed to administer an antibiotic to treat R11's wounds, resulting in a loss of limb. On 12/19/24 at 10:10 AM, the Administrator was notified that the failure to provide treatment, consistent with professional standards of practice, to a Pressure Ulcer (PU)/Pressure Injury (PI), constituted IJ at F686. On 12/19/24 at 10:10 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 11/21/24. The IJ was related to 42 CFR 483.25 Quality of Care. On 12/19/24, the facility provided an acceptable IJ Removal Plan. [...]

Inspectors wroteBased on observations, interviews, record review and review of facility policy, the facility failed to ensure that medications belonging to Resident (R)15 were properly stored, secured, and/or administered prior to staff leaving the room for 1 of 2 residents reviewed.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure that Resident (R)2 was free from physical abuse by Licensed Practical Nurse (LPN)2, for 1 of 19 residents reviewed for abuse.

Inspectors wroteBased on observation, interview and review of the facility policy, the facility failed to maintain an effective pest control program to remain free of pests/rodents, in 1 of 4 units.

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to provide proper safety protocols for 5 out of 5 residents who smoke/vape, Residents (R)1, R2, R3, R4, and R5. Additionally, the facility failed to conduct smoking assessments for 2 out of 5 residents who smoke/vape, R4 and R5. Specifically, residents were smoking vapes in the facility and sharing vapes with other residents. On 04/30/2024 at 09:34 AM, the Administrator was notified that the failure to conduct assessments on residents who smoke/vape and failing to provide proper safety protocols for residents who smoke/vape constituted Immediate Jeopardy (IJ) at F689. On 04/30/2024 at 09:34 AM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 04/30/2024. The IJ was related to 42 CFR 483.25 - Quality of Care. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a homelike environment by providing adequate linens.

Inspectors wroteBased on review of the facility policy, observation, interview and record review, the facility failed to ensure expired medications were removed from the medication and treatment carts, medication rooms; loose pills were removed from the medication carts, as well as failed to apply expiration dates on insulin pens for 4 of 4 units observed.

Inspectors wroteBased on review of the facility policy, observation, and staff interviews, the facility failed to ensure proper sanitation of kitchen equipment and kitchen cleanliness.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure a privacy bag was provided to Resident (R)60's catheter bag for 1 of 2 residents reviewed. The deficiency disregarded the resident's privacy, dignity, and respect and had the potential to cause psychosocial harm. Findings Include: Review of the facility's policy titled, Patient/Resident Rights, with a completed revision date of 06/09/23, revealed, The Facility employs measures to ensure patient and resident personal dignity, well-being, and self-determination are maintained and will educate patients and residents regarding their rights and responsibilities. Residents Rights: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure professional standards of practice were followed regarding medication administration for 2 of 58 residents sampled. (Resident(R)43 and R146.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of 5% or less for 1 of 28 observations. The facility's medication error rate was 7.14%.

Inspectors wroteBased on review of the facility policy, observation, interview and record review, the facility failed to ensure that residents are free of significant medication errors for 1 of 7 sampled Residents (R)43.

Inspectors wroteBased on review of the facility policy, observation, interview and record review, the facility failed to ensure proper cleaning of glucometers for 1 of 14 accu checks observed for glucometer cleaning. Resident (R)20 who received the accu check was at risk for obtaining other illnesses from the improper sanitization of the glucometer.

Inspectors wroteBased on observation, review of facility policy, cleaning schedules, and interview, it was determined the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Sanitation concerns were identified in all areas of the kitchen and had the potential to affect 144 of 151 residents who received meals from the kitchen.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to develop and implement a discharge plan for one (1) of two (2) residents, Resident #142, reviewed for discharges.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a discharge summary for one (1) of two (2) residents, Resident #142, reviewed for discharges.