Magnolia Place Health Care

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to formulate an advance directive was provided for 2 of 6 residents reviewed for resident rights. (Residents #12 and #18) * The facility did not have a valid Out of Hospital-Do Not Resuscitate (OOH-DNR) for Residents #12 and #18. 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 observation, interview, and record review, the facility failed to review and revise resident's comprehensive care plans by the interdisciplinary team after each assessment to reflect the current condition for 3 of 6 residents reviewed for comprehensive care plans. (Residents #12, #23, and #30) 1. The facility failed to ensure the care plan was updated to indicate Resident #12's discontinued g-tube, tube feedings, medications by g-tube, and EBP. 2. The facility failed to ensure Residents #23 and #30's care plans included noncompliance with HOB elevation due to g-tube. These failures could place residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation. The facility failed to ensure dietary staff used the correct sanitizer test strip for the dishwasher sanitation compliance check on 07/27/2026. This failure could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 10 rooms (room [ROOM NUMBER]) observed for homelike environment. The facility failed to ensure room [ROOM NUMBER] was in good repair and did not have a hole and missing wood exposing the wood frame of the toilet seat on 07/27/26 and 07/28/26. This failure could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 3 residents (Resident #23) reviewed for enteral devices. The facility failed to ensure LVN D administered Resident #23's water flush by gravity instead of pushing it through his gastrostomy tube (placement of a tube into the stomach used for nutrition and medication administration) with a syringe on 07/27/2026. This failure could affect residents receiving enteral nutrition, medications, and hydration by placing them at risk of health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of all residents reviewed. 1. The Administrator failed to ensure he, the DON, and the IP received training on Enhanced Barrier Precautions. 2. The Administrator failed to implement Enhanced Barrier Precautions for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. This failure could cause residents not to receive appropriate care resulting in an increase in infections.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure as part of its infection prevention and control program mandatory training included the written standards, policies, and procedures for the program for 11 of 12 employees, new and existing staff, (Administrator, DON, ADON/IP, LVN E, LVN H, CNA A, CNA B, CNA F, CNA I, CNA J, and CNA K) reviewed for training. 1. The facility failed to ensure the Administrator, DON, ADON/IP were trained on EBP (an infection control strategy that uses gloves and gowns during high- contact resident care to reduce spread of MDRO) (MDRO- bacteria that have become resistant to certain antibiotics) 2. The facility failed to ensure LVN E and LVN H were trained on EBP. 3. The facility failed to ensure CNA A, CNA B, CNA F, CNA I, CNA J and CNA K were trained on EBP. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred for 2 of 5 residents (Residents #6 and #64) reviewed for psychoactive medications. 1. The facility failed to ensure Resident #6 had a completed psychotropic consent from the resident or family for Seroquel (antipsychotic medication) before administering to Resident #6 on 09/09/24. 2. The facility failed to ensure Resident #64 had a completed psychotropic consent from the resident or family for Seroquel (antipsychotic medication) and Cymbalta (antidepressant) before administering to Resident #66 on 01/03/25. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 6 residents (Residents #9, #11, #51, #53, #58 and #167) reviewed for infection control. 1. The facility failed to ensure Resident #9 who had an indwelling suprapubic catheter (a tube surgically inserted through the lower abdomen into the bladder to drain urine) and an unstageable pressure ulcer/injury to the left heel (a wound caused by pressure from a surface) had Enhanced Barrier Precautions signage and PPE set up before entering his room and failed to ensure staff wore PPE during high contact resident care activities. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals identified with MI, DD or ID were evaluated for services for 2 of 5 residents (Residents #6 and #19) reviewed for PASRR. The facility failed to ensure the accuracy of the PASRR Level 1 (P1) screen for Resident #6 and Resident #19. This failure could place residents who had a mental illness at risk of not receiving individualized specialized services to meet their needs. 1. Record review of the June 2025 Physician Order indicated Resident #6 was an [AGE] year-old female who was admitted on [DATE]. Her diagnoses included major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life); [...]

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 1 of 5 residents (Resident #6) reviewed for unnecessary medications. * The facility failed to ensure Resident #6 had an appropriate diagnosis on entered orders for her Seroquel (antipsychotic). This failure could place residents at risk for unintended, harmful events attributed to the use of a medication without the appropriate indication.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs were stored in a locked compartments under proper temperature controls, and only permitted authorized personnel to have access to the keys for 1 of 20 resident (Resident #29) reviewed for storage and labeling of medications. The facility failed to ensure Resident #29 did not have over the counter medications, Luden's cough drops, Neosporin and Equate hydrocortisone cream at the bedside. This failure could place residents at risk for misuse of medication, overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications.

Inspectors wroteBased on interview and record review, the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 1 of 1 facility kitchen reviewed for food and nutrition services. The facility failed to designate a person to serve as the dietary manager who met the required qualifications. The facility designated Dietary Supervisor did not have a dietary manager's certification or any other qualifying credentials. This failure could place residents at risk for the spread of foodborne illness and residents not having their nutritional needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the only kitchen reviewed for dietary services. The facility failed to ensure food items were properly labeled with product and expiration date in the refrigerators. These failures could place residents, who ate meals prepared in the kitchen, at risk for food borne illness.

Inspectors wroteBased on interview and record review, the facility's governing body failed to operate and provide services in compliance with all applicable Federal, State and local laws, regulations, and codes for 1 of 1 facility reviewed for Social Worker (SW). The facility did not employ or contract a SW as required by state regulations. This failure could place residents at risk of administrative duties not being carried out attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program was completed for 17 of 17 employees (Administrator, Assistant Administrator, DON, ADON, AD, MD, HS, LVN D, LVN E, LVN F, RN G, CNA H, CNA J, CNA K, CNA L and CNA M) reviewed for training. The facility did not ensure QAPI training was completed by the Administrator, Assistant Administrator, DON, ADON, AD, MD, HS, LVN D, LVN E, LVN F, RN G, CNA H, CNA J, CNA K, CNA L and CNA M. This failure could place staff and residents at risk for not being aware of facility programs, implementation, and monitoring.

Inspectors wroteBased on interview and record review, the facility failed to ensure compliance and ethics training was completed for 17 of 17 employees (Administrator, Assistant Administrator, DON, ADON, AD, MD, HS, LVN D, LVN E, LVN F, RN G, CNA H, CNA J, CNA K, CNA L and CNA M) reviewed for training. The facility did not ensure compliance and ethics training was completed by the Administrator, Assistant Administrator, DON, ADON, AD, MD, HS, LVN D, LVN E, LVN F, RN G, CNA H, CNA J, CNA K, CNA L and CNA M This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training.

Inspectors wroteBased on interview and record review the facility failed to ensure individuals providing services under a contractual arrangement had trainings consistent with their expected roles and failed to keep records of these trainings for 4 of 4 contracted staff. (Dietician, PT, OT, and ST). The facility failed to ensure required trainings were provided for the dietician working in the dietary department at the facility under a contractual agreement. The facility failed to ensure required trainings were provided for PT, OT, and ST working in the therapy department at the facility under a contractual agreement. This failure could place residents at risk of being cared for by contracted staff who have been insufficiently trained to improve resident safety, create a more person-centered environment, and reduce the number of adverse events or other resident complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure employees received the required training effective communications mandatory training was completed for 11 of 17 employees (Administrator, Assistant Administrator, LVN F, RN G, AD, MD, HS, CNA K, CNA L, CNA M, and CNA N) reviewed for training. The facility did not ensure effective communication training was completed by LVN F, RN G, CNA L, CNA M, and CNA N during orientation. The facility did not ensure effective communication training was completed by the Administrator, Assistant Administrator, AD, MD, HS, and CNA K annually. These failures could place residents at risk of miscommunication and social isolation due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to ensure the rights of the resident and responsibilities of the facility were completed for 5 of 17 employees (DON, LVN D, LVN F, CNA K, and CNA N) reviewed for training. The facility failed to ensure the rights of the resident and responsibilities of the facility training was completed by LVN F and CNA N during orientation. The facility failed to ensure the rights of the resident and responsibilities of the facility training was completed by DON, LVN D, and CNA K annually. These failures could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to ensure employees received the required training on Abuse, Neglect, and Exploitation (ANE) for 2 of 11 (DON, LVN F) and dementia management for 1 of 11 employees (LVN F) reviewed for training. The facility did not ensure ANE and dementia management training was completed by the LVN F during orientation. The facility did not ensure ANE training was completed by the DON annually. The facility did not ensure ANE training was completed by the HS annually. This failure could place residents with dementia at risk of abuse, neglect, and exploitation and a poor quality of care by staff with inadequate training when caring for dementia residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure standards, policies, and procedures for an infection prevention and control program was completed for 2 of 17 staff (LVN F and MD) reviewed for training. The facility did not ensure infection prevention and control training was completed by LVN F during orientation. The facility did not ensure infection prevention and control training was completed by the MD annually. These failures could place residents at risk of illness due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to ensure CNAs completed Abuse, Neglect, and Exploitation (ANE) and dementia management trainings for 2 of 6 CNAs (CNA K and CNA N) reviewed for training. The facility did not ensure ANE and dementia management trainings were completed by CNA N during orientation. The facility did not ensure ANE and dementia management trainings were completed by CNA K annually. This failure could place residents with dementia at risk of abuse, neglect, and exploitation and a poor quality of care by staff with inadequate training when caring for dementia residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure training on behavioral health was completed for 11 of 17 employees (Administrator, Assistant Administrator, AD, MD, HS, LVN F, RN G, CNA K, CNA L, CNA M and CNA N) reviewed for training. The facility did not ensure behavioral health training was completed by LVN F, RN G, CNA L, CNA M and CNA N during orientation. The facility did not ensure behavioral health training was completed by the Administrator, Assistant Administrator, AD, MD, HS, and CNA K annually. This failure could place residents with behaviors at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the status for 1 of 20 residents reviewed for assessments. (Resident #24). The facility failed to complete an accurate resident assessment for Resident #24. Resident #24's resident assessment did not indicate she received special treatments, procedures, and programs of oxygen therapy. This failure could place residents at risk of not having individual needs met and a decreased quality of life.