Magnolia Manor Methodist Nsg C

Based on observations, staff interviews, record review, and review of the facility policy titled, Care Plans-Comprehensive Person-Centered the facility failed to implement appropriate individualized interventions on the comprehensive care plan for a resident requiring oxygen therapy management for one of 24 residents (R) (R65) receiving oxygen. This deficient practice had the potential to place the residents at risk for unmet care needs.Findings include:Review of the undated policy Care Plans-Comprehensive Person-Centered revealed under procedural guidelines: . 2. The care plan is developed from the resident assessment (MDS (minimum data set) and in coordination with the attending physician's regimen of care.Review of the electronic medical record (EMR) for R65 revealed diagnoses that included butare not limited to unspecified asthma, uncomplicated.Review of Physician Orders dated 03/24/2026 for R65 revealed orders for oxygen at two liters per minute (LPM) via nasal canula (NC).Review of the care plan for R65 revealed the resident required oxygen therapy related to respiratory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews, the facility failed to ensure an environment free from potential hazards by not removing aerosol cans from the bedside for two of 50 sampled residents (R) (R34 and R37). This deficient practice increased the risk of potential accidents. Findings include: 1. Observations on 04/28/2026 at 11:42 AM, 04/29/2026 at 10:33 AM, and 04/30/2026 at 10:12 AM of R37's room revealed one aerosol container (air freshener) placed on top of the nightstand located next to R37's bed. During an interview on 04/30/2026 at 10:43 AM, Nurse Supervisor Licensed Practical Nurse (LPN) GG and Certified Nursing Assistant (CNA) HH confirmed the aerosol container was present in R37's room. Both staff stated that aerosol containers were not permitted in resident rooms due to safety concerns for residents who wander. CNA HH and LPN GG immediately removed the aerosol container from R37's room at the time of the interview. During an interview on 04/30/2026 at 11:48 AM, the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) confirmed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, and review of the facility's policy titled, Oxygen Therapy, the facility failed to ensure the physician's order for oxygen administration was followed for one of 24 Residents (R) (R65) reviewed for oxygen administration. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs and a diminished quality of life.Findings include:Review of the facility's undated policy titled Oxygen Administration under the section titled Intent revealed: It is the intent of (corporate name) facilities to ensure that oxygen is administered appropriately to residents to improve oxygenation and provide comfort to residents experiencing respiratory difficulties.Review of the electronic medical record (EMR) for R65 revealed diagnoses that included but are not limited to unspecified asthma, uncomplicated.Review of 65's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed, Sections C (Cognitive Patterns), a Brief…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews, interviews and the facility policy titled Surveillance for Infections, the facility failed to follow the Department of Public Health (DPH) recommendations for diagnostic testing for 33 symptomatic residents on six of six Units (Unit 1, Unit 2, Unit 3, Unit 4, Unit 5, Unit 6) involved in an epidemiological qualified infectious disease outbreak. The deficient practice increased the risk for continued spread of infection.Findings includeReview of the policy Surveillance for Infections revised September 2017 documented under Policy Interpretation and Implementation: 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infections, to guide appropriated interventions and to prevent future infections. 8. a. The Infection Preventionist and the Attending Physician will determine if laboratory tests are indicated, and whether special precautions are warranted.Review of the gastrointestinal illness (GI) outbreak synopsis provided by the facility, documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interviews and the facility policy titled Restraints/Bed Rails, the facility failed to ensure one resident (R) (R1) from a sample of 11 residents was free from being restrained with a gait belt while in a wheelchair. The deficient practice placed R1 at risk of adverse clinical outcomes. Findings includeReview of the policy Restraints/Bed Rails dated October 2016, documented, under Intent: It is the intent of the (named) facility that right of residents to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms is honored at all times.Review of the medical records revealed R6 was admitted to the facility on [DATE], with the following diagnoses that included but are not limited to type 2 diabetes mellitus, mood disorder, hypertension, chronic obstructive pulmonary disease, and benign prostatic hyperplasia.Review of the quarterly Minimum Data Set (MDS) for R6 with an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure food safety, sanitary conditions and the prevention of foodborne illness were maintained. This was evidenced by one of one walk-in freezer temperature gauges that displayed multiple temperatures greater than 20 degrees Fahrenheit (F) by three internal thermometers, which lead to food thawing. Additional failures included a large quantity of raw chicken pieces allowed to sit, unrefrigerated, in the frying area of the kitchen for more than four hours before placing the remaining unused portions into the same freezer with elevated temperature for storage. The facility staff failed to ensure meals served from the steam table were served under sanitary conditions by failing to change gloves, perform hand hygiene when staff changed job duties, ensuring hairnet and beard guards were used, and failed ensure steam table pan covers and food were protected from chemical contamination. This deficient practice impacted 131 of 139 residents that received an oral diet. The findings include:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to refer residents with a newly identified mental disorder or condition to the appropriate state agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation. This affected one (1) of 2 residents reviewed for PASARR Level II, Resident (R) #22. Review of the facility's policy titled Assessment of Resident Minimum Data Set/Resident Assessment Instrument (MDS/RAI), reviewed and updated October 2016, revealed: Intent - It is the intent of Magnolia Manor facilities that the MDS/RAI be completed per MDS/RAI and regulatory guidelines . Procedural Guidelines . 4. Assessments should be coordinated with the PASARR program. This includes incorporating the recommendations from the PASARR Level II determination and the PASARR evaluation into the assessment, care plan and transitions of care. Any significant change in resident's physical or mental condition should be reported to the state mental health authority or state…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy, staff failed to complete the assessments intended to identify deficits in ability to smoke safely for Resident (R) #22. This affected one (1) of three (3) residents sampled for smoking. The findings include: Review of facility policy entitled, Resident Smoking Guidelines, revealed: Intent - Magnolia Manor realizes the threat that smoking presents to the health and safety of the residents in our facilities . All residents who wish to smoke will be allowed to do so only in designated areas of the facility . Procedural Guidelines . 2.Resident Smoking Assessment List: A. The SSD and/or Care Plan Team Representative will assess each smoker initially, annually, with significant change and quarterly with OBRA MDS schedule to determine the amount of assistance needed and appropriately complete and/or revise the Resident Smoking Assessment List. SSD should document in the social services progress note that the assessment was completed and refer to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and review of facility policy titled, Medication Storage in the Care Center, the facility failed to safely store and secure medications in one of four medication rooms by leaving the medication room door unsecure and open ajar approximately three inches located in the Memory Care Unit. The deficient practice had the potential to allow unauthorized access by residents and visitors to medical equipment and medications stored in medication storage room. Findings include: Review of facility policy titled, Medication Storage in the Care Center last reviewed and updated April 2016 revealed under Procedural Guidelines: 2. Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts and medication supplies are locked or attended by persons with authorized access. Observation on 12/6/2023 at 2:46 pm on Unit 4, the Memory Care Unit, revealed the medication room on that unit is located adjacent to the nurse's station and in close proximity to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of the facility policy titled, Resident Rights, the facility failed to maintain the dignity and privacy of three of nine residents (R), R26, R45, and R280, by leaving their urinary catheter bags uncovered and visible from the doorways of their rooms. Findings include: Review of the facility policy titled Resident Rights review date October 2016 revealed under Facility Responsibilities: The facility Must: 1. Treat residents with respect and dignity and provide care and services for the residents in a manner and in an environment that promotes maintenance or enhancement of the resident's quality of life and protect and promote the resident's rights. 1.Review of the electronic medical record (EMR) for R26 revealed a [AGE] year-old male admitted to the facility with diagnoses to include Alzheimer's disease, dementia with behavioral disturbance, and acute failure, and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and physician interviews, record review, review of the facility documents and procedural guidelines titled, Medical Director Employment Agreement, Physician Services - The Medical Director's Role and Responsibilities, and Professional Staff Application - Staff Responsibilities, the facility failed to follow the current Centers for Medicare and Medicaid Services (CMS) regulations in regard to the frequency of physician visits for residents in nursing homes for one of 124 residents (R118). The deficient practice had the potential to prevent R118 from receiving the required level of care delivered by the facility. Finding include: Review of the facility's procedural guidelines titled Physician Services the Medical Director's Role and Responsibilities under Intent:15. Assist the facility in the assurance that physician services are in compliance with current rules, regulations, and long-term guidelines. Review of facility documents titled, Medical Director Employment Agreement signed by Doctor (Dr…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and physician interviews, record review, review of facility documentation, and a review of the facility procedural guidance titled, Credentialing of Professional Staff, the facility failed to ensure one of 124 residents (R118) had complete access to the resident's medical record which is necessary to care for residents in a safe effective manner. The deficient practice had the potential to hinder the ability of all staff to deliver unfragmented resident care. Findings include: Review of the facility's procedural guidelines titled, Credentialing of Professional Staff last revised on December 2012 revealed under Staff Responsibilities: The Professional Agrees to 10. Write, sign and date progress notes descriptive on the resident's condition in a timely manner. Under Facility Responsibilities: The Facility shall be responsible for: 1. Assuring that the Staff Professional has complete access to all records and supplies within the Facility necessary for the performance of his/her duties. Under Charting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record reviews, and a review of the facility's policy titled, Infection Prevention and Control, the facility failed to maintain infection control standard precautions by, not keeping a nebulizer mask and Continuous Positive Airway Pressure (CPAP) nasal cushions enclosed inside a bag when not in use for two of 18 Residents (R) R99 and R112. Findings Include: 1. Review of the facility policy titled, Infection Prevention and Control last revised and approved February 2020 revealed, the intent of Magnolia Manor facilities is to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and prevent the development and transmission of disease and infection. Observations on 12/5/2023 at10:25 am, 12/6/2023 at 9:15 am, and 12/7/2023 at 11:45 am R99's nebulizer machine is sitting on the bed-side table with the reusable mask lying on top of the machine, not secured in a dated and labeled bag. Record review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.