Magnolia Manor of Columbus Nursing Center - East

Inspectors wroteBased on observation, staff interviews, and review of facility policy titled Infection Prevention and Control, the facility failed to ensure that infection control hand hygiene practices were followed by three of three Licensed Practical Nurses (LPN) (LPN BB, LPN CC, and LPN AA) observed during medication administration. The deficient practice had the potential to contribute to the transmission of infectious diseases among residents and staff.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a clean and comfortable environment for one of 97 resident rooms (room [ROOM NUMBER]). Specifically, the self-contained wall-mounted air conditioning unit (PTAC) displayed heavy substance buildup on the filter and had the potential to affect patient comfort and safety.

Inspectors wroteBased on interviews, record review, and facility document review, the facility failed to implement the care plan for one of three residents (R) (R3) reviewed for falls. R3's care plan instructed staff to use two people for bed mobility. Certified Nurse Aide (CNA)1 provided care alone, and as a result, R3 fell from the bed during care, sustaining a hematoma and laceration from the fall.

Inspectors wroteBased on interviews, record review, facility document review, and policy review, the facility failed to ensure one of 19 sampled residents (R) (R3) was safe from accidents and hazards resulting in injuries. Harm was identified as having occurred on 3/24/2025, when Certified Nurse Aide (CNA)1 failed to follow the plan of care for R3, resulting in R3 falling from the bed and sustaining a hematoma and laceration from the fall.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain a facility-wide effective pest control program for the current facility population of 89 residents. This failure had the potential to lead to further pest infestation in the facility and feelings of discomfort or spread of infection among the residents.

Inspectors wroteBased on interviews, document review, and facility policy review, the facility failed to conduct thorough investigations for five of 19 sampled residents (R) (R1, R2, R3, R5, and R6). Failure to conduct a thorough investigation could result in further incidents occurring due to unknown factors.

Inspectors wroteBased on staff interviews and record review, the facility failed to submit for a Preadmission Screening and Resident Review (PASRR) Level II after a new mental health diagnosis was added for one of three residents (R) (R17) reviewed for PASRR Level II. This deficient practice had the potential to affect the level of care and services provided for R17.

Inspectors wroteBased on staff interviews, record review, and review of facility policies titled, Assessing Vital Signs, and Care Planning-Interdisciplinary Team, the facility failed to follow the comprehensive Care Plan regarding weekly weights for one of 33 residents (R) (R82) in the sample.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Scope of Assessments, the facility failed to complete an admission nutrition assessment for one of five residents (R) (R82). The deficient practice had the potential to prevent R82 from receiving required nutrients in accordance with the resident's nutritional needs.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Oxygen Therapy, the facility failed to ensure oxygen (O2) was administered according to physician order for two of 15 residents (R) (R5 and R59) receiving oxygen. In addition, the facility failed to ensure respiratory equipment was maintained in a sanitary manner for one of 15 residents (R11) receiving oxygen. The deficient practices had the potential to place R5, R59, and R11 at risk for medical complications, unmet needs, and a diminished quality of life.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Infection Prevention and Control, the facility failed to ensure that the Pneumococcal vaccine was administered to three of 18 residents (R) (R12, R13, and R16).

Inspectors wroteBased on staff interviews and record review, the facility failed to ensure that medications were administered as care planned and ordered, for one of three residents (R) (R1). The deficient practice had the potential to prevent R1 from obtaining care in accordance with their care needs.

Inspectors wroteBased on staff interviews, and record review, the facility failed to ensure that medications were administered, and fingerstick blood sugar levels were obtained, as ordered by the physician, for one of three residents (R) (R1). The deficient practice had the potential to increase the probability of R16 blood glucose levels not to be maintained according to the residents' care needs.

Inspectors wroteBased on staff interviews, record reviews, and review of the facility policies titled, Infection Prevention and Control, and COVID-19 Response, the facility failed to maintain an infection control program that included thorough and complete surveillance for one of 16 residents (R) (R16), who tested positive for COVID-19.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a clean and homelike environment for residents in three of four hallways in the facility. As evidenced by dark brown stains with a black substance on ceiling tiles (outside of room [ROOM NUMBER], 207, and 208) and four air ventilation grates were covered with an unidentified black substance (on the outside of rooms 202, 215, 216, and 227) on three of four hallways

Inspectors wroteBased on observation, interview, record review, and review of policy titled, Abuse Prohibition/ Reporting and Investigation, it was determined the facility failed to ensure allegations of abuse and allegations of misappropriation of property were reported to the State Agency for two (Resident #38 and Resident #88) of two residents reviewed for abuse. Specifically, the facility failed to ensure alleged misappropriation of Resident #38's medication was reported and failed to ensure alleged physical abuse for Resident #88 was reported.

Inspectors wroteBased on interviews, record review, and review of policy titled, Abuse Prohibition/ Reporting and Investigation, it was determined the facility failed to ensure residents were free from misappropriation of property for one (Resident #38) of two residents reviewed for abuse, neglect, misappropriation of resident property, and exploitation. Specifically, the facility failed to ensure Resident #38 was free from alleged misappropriation of property related to missing medication.

Inspectors wroteBased on observation, record review, interviews, and document and review of policy titled, Abuse Prohibition/Reporting and Investigation revealed, it was determined that the facility failed to ensure established abuse policies and procedures were implemented after receiving an allegation of abuse for one [Resident (R) #88] of two residents sampled for the implementation of abuse prohibition policies and procedures. Facility staff had not been educated what to do after receiving an allegation of abuse, and as a result, an allegation of physical abuse failed to be reported.

Inspectors wroteBased on observation, interview, record review, and review of policy titled, Abuse Prohibition/ Reporting and Investigation, it was determined the facility failed to ensure an allegation of abuse was investigated for one (Resident #38) of two residents reviewed for abuse. Specifically, the facility failed to investigate alleged misappropriation of Resident #38's narcotic medication.

Inspectors wroteBased on observations, interviews, record review, and review of policy titled, Oxygen Therapy-Mask and Nasal Cannula, it was determined the facility failed to store the oxygen tubing and nasal cannula in a sanitary manner when not in use for one (Resident [R] #41) of two residents.

Inspectors wroteBased on observations, interviews, record review, and review of policy titled Dental Services, it was determined that the facility failed to ensure one [Resident (R) #37] of one resident obtained needed dental services after the resident voiced experiencing sore gums. This failure resulted in the resident experiencing gum discomfort and a potential for a diminished quality of life. The facility census was 101 residents.