Magnolia Post Acute Care

Inspectors wroteBased on interview and record review, the facility failed to ensure three out of three residents (Resident 1, 2, and 3) were free from sexual abuse when:1. Resident 1 stated certified nursing assistant (CNA) 4 fondled her clitoris and inserted his fingers in her vagina during care.2. Resident 2 stated CNA 4 massaged her vagina during a brief change. 3. Resident 3 stated CNA 4 inserted his fingers into her vagina during a brief change.4. The facility hired CNA 4 with reference checks that reflected negative past employment performance. As a result of this deficient practice, Resident 1, 2, and 3 experienced psychosocial harm (damage to a person's mental, emotional, and social well-being that was caused by their environment or experiences), stating the incidents with CNA 4 made them feel angry, humiliated, embarrassed, ashamed, and worried.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 2's grievance corrective action was followed through when the facility assigned certified nursing assistant (CNA) 4 to the resident after Resident 2 requested not to assign CNA 4 to provide care to her as indicated in her grievance on 7/21/24. As a result of this deficient practice, Resident 2's request to not be provided care by CNA 4 was not honored and the resident was at risk for further abuse by CNA 4. Cross reference F600 and F656.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate and identify sexual abuse in the facility after conducting three investigations when:1. The facility unsubstantiated Resident 1's sexual abuse allegation against certified nursing assistant (CNA) 4.2. The facility unsubstantiated Resident 2's sexual abuse allegation against CNA 4.3. The facility unsubstantiated Resident 3's sexual abuse allegation against CNA 4.4. The facility's investigation into the allegations against CNA 4 indicated the CNA had only favorable pre-employment references when this was not correct. In addition, the facility failed to ask clarifying questions during the course of their investigations to fully understand the residents' allegations. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan in a timely manner after Resident 2 filed a grievance and requested certified nursing assistant (CNA) 4 to not be assigned to her. As a result of this deficient practice, Resident 2's request to not be provided care by CNA 4 was not honored and the resident was at risk for further abuse by CNA 4.

Inspectors wroteBased on observation, interview, and record review the facility failed to evaluate and/or offered to help formulate (assist) an advanced directive (AD- a legal document indicating resident preference on end-of-life treatment decisions) for three of eight residents (Resident 49, 113 and 114) reviewed. This deficient practice placed all 92 residents at risk of not having their medical care wishes honored in the event of a health emergency or if they become unable to communicate leading to unwanted treatments or confusion about their care preferences.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the competency of one dishwasher for chlorine testing related to dishware when using the low temperature dishwasher. This failure increased the risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly cover a caramel (sugar or syrup heated until it turns brown) sauce in the walk-in refrigerator. This failure had the potential for promoting foodborne illnesses.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to fix the following equipment for one of 21 sampled residents (Resident 78):1. right upper bed railing2. sliding glass door3. sliding screen door4. TV remoteThe failure to fix Resident 78's equipment did not create a homelike environment for Resident 78.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 88) was free from unnecessary medications by administering olanzapine (a medication used to treat symptoms such as hallucinations or delusions in patients with serious mental illnesses) without an appropriate diagnosis. This failure had the potential for increased risks associated with the use of psychotropic medications (substances that affect the brain's activities and influence mental processes and behaviors) and excessive sedation. During a review of Resident 88's clinical record, the admission Record indicated Resident 88 was admitted to the facility on [DATE] with diagnoses which included cerebrovascular disease (a stroke), major depressive disorder (a condition that causes a persistent feeling of sadness), and a history of falling. [...]

Inspectors wroteBased on interview and record review, the facility failed to update an intervention for nutrition care plan for one of 21 sampled residents (51). This failure had the potential for Resident 51's nutritional care plan to be mismanaged.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that interventions to prevent the development of pressure injuries (wounds caused from pressure to a bony prominence) for one of 12 sampled residents (Resident 23) was implemented. This failure had the potential for increased skin breakdown, infection and decreased physical and psychosocial well-being. According to the facility's admission Record, Resident 23 was admitted on [DATE] with diagnoses which included pressure-induced deep tissue damage (a type of pressure injury) of sacral region (the bottom of the spine), and functional quadriplegia (the inability to move all four limbs). During a review of the Minimum Data Set (MDS- an assessment tool), Resident 23 was dependent on staff for putting on and taking off footwear. [...]

Inspectors wroteThe facility did not ensure safety with bed rails and proper use of a hoyer lift for two of 21 sampled residents (Resident 78 and Resident 23) according to the facilities policies and procedures.

Inspectors wroteBased on observation, interview and record review the facility did not practice infection control according to facility policies and procedures and standards of practice. These failure had the potential to increase the spread of infection.

Inspectors wroteBased on interview, and record review, the facility failed to provide proper discharge planning to ensure a safe and coordinated discharge for one of three sampled residents (Resident 1) during a complaint investigation. This deficient practice placed Resident 1 at risk for an unsafe discharge and re-hospitalization.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policies and procedures for investigating missing items to protect the personal property for one reviewed resident (Resident 1) during a complaint investigation. This deficient practice placed all 91 residents at risk for loss of personal belongings and potential exploitation (taking advantage of a resident for personal gain), especially those with impaired cognition (memory or thinking).

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to ensure a significant change Minimum Data Set (MDS) was submitted timely for 1 (Resident #53) of 18 resident MDSs reviewed.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) was accurate for 1 (Resident #41) of 18 sampled residents reviewed for MDS accuracy.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level I assessment was coded accurately for 1 (Resident #10) of 3 sampled residents reviewed for PASRR.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to ensure a care plan was completed for diuretics for 1 (Resident #53) of 5 sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to follow their own policy regarding receipt of narcotics (controlled substance) for 1 of 2 sampled residents. This failure occurred when a licensed nurse did not check or inventory medications which included narcotics delivered by the pharmacy to the facility. As a result, the whereabouts of Resident 1's narcotic medication was not known. This deficient practice had the potential to delay pain medication administration, could affect residents ' safety and created an opportunity for drug diversion.

Inspectors wroteBased on interview and record review the facility failed to notify a resident ' s (4) physician regarding an altered mental status (confusion, disorientation, difficult to arouse) for one of one resident reviewed for change in condition. This failure had the potential to delay care and treatment to address the resident ' s change in condition. Resident 4 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease stage three (mild to moderate loss of kidney function) and discharged to the hospital on 3/28/24 according to the facility ' s admission Record. An interview on 5/3/24 at 9:55 A.M., with licensed nurse (LN) 1 was conducted. LN 1 stated, for a change in resident ' s condition, the physician will be notified immediately. LN 1 stated vital signs will be taken, provide emergent treatment as needed, and call 911 if necessary. [...]

Inspectors wroteThe following reflects the findings of the California Department of Public Health during an abbreviated standard survey. Complaint Number: CA00334806 Category: Quality of Care/Treatment Representing the Department: Health Facilities Evaluator Nurse(s): 39111 and 49330 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for the complaint number: CA00884806 (Refer to F-tag 656). Based on observation, interview, and record review, the facility failed to ensure resident-specific care plans were developed for two of three residents (Resident 1 and Resident 2) when: 1. Resident 1 did not have a written care plan developed to address the presence of a cardiac pacemaker (a device used to treat an irregular heartbeat). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure call lights were answered in a timely manner for ten confidential residents (CR- 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10). This failure had the potential to result in residents' needs not being met, which had the potential to result in physical and emotional harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy on abuse for one of 27 residents (435) when the facility did not follow abuse reporting after the resident reported the incident to the Director of Nursing (DON). This failure had the potential to place Resident 435 at risk for physical and/or emotional harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) in a timely manner, for one of 27 residents (435) reviewed for abuse. This failure had the potential to cause physical and/or emotional harm to Resident 435.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct an investigation of alleged abuse for one of 27 residents (435) reviewed for abuse. As a result, the alleged licensed nurse (LN) was not suspended and reassigned to a different nurses station. This failure had the potential to result in physical and/or emotional harm for Resident 435.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a baseline care plan related to the use of an indwelling catheter, in a timely manner for one of four residents (183), reviewed for urinary catheter care. This failure had the potential to affect Resident 183's coordination, treatment needs, and care.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a care plan related to oxygen use for one of one resident (23) reviewed for oxygen treatment. This failure had the potential to affect Resident 23's oxygen treatment and care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to communicate food allergies to the dietary department for one of four residents (62) reviewed for food preferences. In addition, a physicians order related to oxygen use was not followed for one of one resident (23) reviewed for oxygen therapy. These failures had the potential to affect Resident 62 and 23's physical health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure low air loss mattresses (LAL [mattress designed to prevent and treat pressure ulcers; localized damage to the skin and/or underlying tissue]) were set at the correct pressure for two of eight residents (82 and 6), reviewed for pressure ulcers. These failures had the potential to cause an existing pressure ulcer to worsen for Resident 82, and for Resident 6 to develop a pressure ulcer.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. Expired medications (meds) were discarded, 2. Expired intravenous (IV) supplies (infusion set, latex surgical gloves, silicone dressing, secondary IV tubing) were discarded, 3. The temperature for the med refrigerator was consistently monitored for one of the two refrigerators in North station's med room and, 4. A can of beer found in the med room was discarded. These failures had the potential for residents to receive expired meds and supplies, affect the efficacy of meds and the effectiveness of treatments. In addition, failure to discard a can of beer posed a risk of staff consuming alcohol while on duty.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a visitor (Food service delivery employee [FSD] employee) to the facility was screened for signs and symptoms of COVID-19 (highly infectious virus). In addition, the facility did not replace a contaminated shower curtain in a residents' communal bathroom and a resident's bedroom. Furthermore, a facility staff member did not consistently perform hand hygiene while providing resident care. These failures had the potential to place staff, residents, and visitors at risk of viral and/or bacterial infections.