Magnolia Senior Care, LLC

Inspectors wroteBased on observation, interviews, record review and facility policy review the facility failed to implement comprehensive care plan by not following physician orders related to the application of compression hose, nurses cleaning and changing tubing on suction device and wearing Personal Protective Equipment (PPE) while providing direct care for three (3) of five (5) care observations. Resident #6, Resident #8, and Resident #22. [...]

Inspectors wroteBased on observation, interviews, record review and facility policy review the facility failed to follow physician orders, as evidenced by not applying compression hose for a resident and not cleaning suction equipment for two (2) of (2) residents reviewed. Resident #6 and #22. Findings Include:Record review of the facility policy Provision of Quality Care dated 2025, revealed, Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice. Each resident will be provided with care and services to attain or maintain his/her highest practicable physical, mental and psychosocial well-being . Resident #6During an observation and interview on 04/13/2026 at 11:20 AM, Resident #6 was observed in bed and stated, My legs are swollen and I do not have my compression hoses on yet. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate and complete submission of staffing data through the Payroll-Based Journal (PBJ) system to the Centers for Medicare and Medicaid Services (CMS) for one (1) of four (4) FY (fiscal year) quarters reviewed. This deficient practice had the potential to result in inaccurate public reporting of staffing levels and misrepresentation of the facility's actual staffing, including the omission of contract nursing staff hours.

Inspectors wroteBased on observations, interviews, record reviews and facility policy review the facility failed to prevent the possibility of spreading infection as evidenced by not wearing proper personal protective equipment (PPE) and not adhering to Enhanced Barrier Precautions (EBP) during high contact care, not performing hand hygiene prior to care and not protecting a yankeaer from bacteria, changing tubing, and cleaning a suction device for three (3) of five (5) care observations. Resident# 8, Resident #22 and Resident #49.

Inspectors wroteBased on observations, interviews, record review and facility policy review the facility failed to honor residents' rights as evidenced by posting of personal signage in the resident's room for one (1) of (14) residents reviewed. Resident #6. Findings Include: Record review of the facility's Resident Rights Policy dated 2025 revealed the facility will ensure that all direct care and indirect care staff members, including contractors and volunteers, are educated on the rights of residents and the facility's responsibility to provide proper care to residents. On 04/13/2026 at 11:20 AM, during an observation and interview revealed Resident #6 was in bed. Observed signage on the wall Please put on compression hose daily even when resident is in bed. They are to be removed every night at bedtime Resident #6 stated, my legs are swollen, I do not have my compression hoses on yet. [...]

Inspectors wroteBased on facility policy review, interviews, and record reviews, the facility failed to ensure Certified Nursing Assistants (CNAs) followed the comprehensive plan of care for manual assistance for two (2) of four (4) sampled residents. Resident #1 and Resident #2.

Inspectors wroteBased on observation, interviews, record review and facility policy review, the facility failed to ensure a resident was free from accident hazards, causing harm, when Resident #1 was dropped from a lift. Resident #2 had the possibility of an accident hazard when staff transferred the resident using one person assistance, instead of the assessed two (2) person assistance for (2) of four (4) resident sampled for accidents and hazards. Resident #1 and Resident #2.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure a comprehensive care plan was developed to include a resident's diagnosis of Dementia, to provide information related to treatment and appropriate interventions for one (1) of 14 care plans reviewed. Resident #9 Findings Include: A review of the facility's policy titles, Comprehensive Care Plans, dated 10/23, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment . [...]

Inspectors wroteBased on resident and staff interview, record review, and facility policy review, the facility failed to ensure dietary staff supported and respected a resident's right to make choices about his or her meal preferences for one (1) of (14) sampled residents. Resident #46. Findings Include: A review of the facility policy titled, Residents Rights, (undated), revealed, . Freedom to Choose . We will accommodate as much as possible individuals needs and preferences in daily routines and activities. Self-determination and reasonable accommodations of individual choices are an important part of residents' rights . On 12/15/24 at 12:25 PM, during an interview with Resident #46, he mentioned that sometimes he likes the food, but he does not have alternative options available and would sometimes prefer to choose different foods instead of eating what is provided to him. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure an enteral feeding pump was operated by licensed staff for one (1) of nine (9) residents observed with Percutaneous Endoscopic Gastrostomy (PEG) tube feedings.

Inspectors wroteBased on observation, interviews, record review and facility policy review the facility failed to provide appropriate and sufficient care to prevent the possibility of Urinary Tract Infections (UTIs) for one (1) of four (4) incontinence care observations. Resident #15. Findings Include: Review of the facility's Perineal Care (peri-care) for Female policy, revised 4/2017, revealed, .The purpose of this procedure is to provide appropriate care according to current standards of practice . Procedure .8. Washes genital area, moving from front to back, while using a clean area of the washcloth or wipe for each stroke. 9. Using a clean washcloth or wipe, rinse soap from genital area, moving from front to back, while using a clean area of the washcloth or wipe for each stroke . [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure infection control measures were consistently implemented to prevent the development and/or transmission of infection for two (2) of sixteen (16) sampled residents.