Magnolia Manor Of Marion County

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and/or implement a comprehensive care plan related to fall prevention and contracture management for two residents (R) (R9 and R16) from a sample of 29 residents. The deficient practice had the potential to prevent residents from reaching their highest practicable level of functioning and compromise resident safety. Findings include:1. Review of R9's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed R9 was admitted to the facility on [DATE] with diagnoses of but not limited to dementia with agitation, diabetes, and peripheral vascular disease.Review of R9's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/05/25 and located under the RAI [Resident Assessment Instrument] tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15 which indicated moderate cognitive impairment. Review of R9's Care Plan dated 07/19/2025 revealed,…

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 record review, interview, and document review, the facility failed to ensure medications were held according to parameters ordered by the physician for one of five residents (R) (R9) reviewed for unnecessary medications. The deficient practice increased the potential risk of adverse clinical outcomes.Findings include:Review of R9's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed admitted to the facility on [DATE] with diagnoses including but not limited to essential primary hypertension, dementia with agitation, diabetes, and peripheral vascular disease.Review of R9's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/05/2025 and located under the RAI [Resident Assessment Instrument] tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15 which indicated moderate cognitive impairment. Review of R9's Orders tab of the EMR revealed a physician's order dated 07/11/2025, for carvedilol (medication to…

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 observation, record review, and interviews, the facility failed to ensure one resident (R) (R16) from a sample of 29 residents received appropriate services for a contracture. This deficient practice had the potential for worsening contracture of the right hand and prevent maximum practicable level of function.Findings include:Review of R16's Face Sheet located in the electronic medical records (EMR) under the Resident tab indicated an admission date of 12/14/2022, with diagnoses of but not limited to chronic kidney disease and type 2 diabetes.Review of R16's annual Minimum Data Set (MDS) located in the EMR under the RAI tab with an Assessment Reference Date (ARD) of 12/05/2025 indicated a Brief Interview for Mental Status (BIMS) score of two which indicated severe cognitive impairment.Review of R16's annual Care Area Assessment (CAA) located in the EMR under the RAI tab with an assessment date of 11/19/2025, documented the resident was at risk for functional decline because of contractures.Review of R16's Care Plan located in the EMR under the RAI tab revealed no mention…

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, record review, and policy review, the facility failed to ensure identified fall prevention interventions were implemented for one of three residents (R) (R9) reviewed for falls. The deficient practice increased the risk of falls for R9.Findings include:Review of R9's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed R9 was admitted to the facility on [DATE] with diagnoses of but not limited to dementia with agitation, diabetes, and peripheral vascular disease.Review of R9's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/05/25 and located under the RAI [Resident Assessment Instrument] tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15 which indicated moderate cognitive impairment.Review of R9's Care Plan dated 07/19/2025 revealed, [R9] has history of falling, prior to admission R/T [related to] low b/p [blood pressure]. She continues to be at risk for falls, no safety…

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 the facility's policy titled, Pureed Food Preparation, the facility failed to ensure the nutritional value of meat during the pureed process. Specifically, the facility failed to follow the recipe by not measuring all ingredients while pureeing meat. The deficit practice had potential to place 16 of 16 residents who received a pureed diet at risk of decreased nutritional intake. Finding included: Review of the facility's undated policy titled, Pureed Food Preparation revealed, Facility will prepare pureed foods in a manner that sustains nutritional value and taste. The foods will be pureed to assure the desired consistency. Procedure: Pureed foods will be made from regular menu items to assure similar taste and nutritional quality. Recipes for regular menu items will be followed during production. Puree procedures are as follows: 7. Please follow manufacturer's directions when adding thickeners to foods to assure proper consistency. An interview and observation on 1/15/2025 at 10:15 am with [NAME] AA revealed that she prepares…

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, and review of the facility's policy titled, Residents Rights/ Facility Responsibilities, the facility failed to provide a safe/clean/comfortable/homelike environment for six rooms of (49) rooms (Rm) (Rm 112, RM [ROOM NUMBER], RM [ROOM NUMBER], RM [ROOM NUMBER], RM [ROOM NUMBER]b, and RM [ROOM NUMBER]). Specifically, RM [ROOM NUMBER], RM [ROOM NUMBER] and RM [ROOM NUMBER] all had leaking faucets, RM [ROOM NUMBER]b had a broken bed side dresser, RM [ROOM NUMBER] had a blown light bulb in the room, and RM [ROOM NUMBER] had dirty blinds, and the air conditioning unit was discolored with a brown tent. Findings include: 1. Review of the facility's policy titled Residents Rights/ Facility Responsibilities with a revised date of 12/18/2023 revealed, Intent -It is the intent of [named facility] to ensure each resident is treated with respect and dignity and care, in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. We believe…

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 review of the facility's policy titled, Restorative Nursing, the facility failed to obtain a physician order for one of five residents (R) (R3) with known contractures. The deficient practice had the potential to increase the progression of contractures for R3. Findings included: Review of the facility's policy titled, Restorative Nursing, reviewed and updated March 2014, under the Procedural Guidelines section revealed, The facility's rehabilitative/restorative nursing care program is designed to assist each resident to maintain their highest level of functioning. Review of the electronic medical record revealed R3 had diagnoses of but not limited to, intellectual disabilities, feeding difficulties, cerebral palsy, and anxiety disorder. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] Section C- cognitive patterns, revealed a Brief Interview for Mental Status (BIMS) score of 9 which indicated moderate cognitive impairment; Section…

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 observation, staff interviews, record review, and review of the facility's policy titled, Medication Administration-General, the facility failed to ensure a medication error rate of less than five percent (5%) during medication administration for one of three residents (R) (R14). There were 26 opportunities observed and two medication errors for a medication error rate of 7.69%. This deficient practice had the potential to cause adverse drug reactions for R14. Findings included: Review of the facility's undated policy titled, Medication Administration-General, under the Guidelines section it was revealed, Prior to medication administration: The nurse should always identify the patient and verify the patient is available for medication administration. The nurse should read the administration directions on the MAR (Medication Administration Record) and verify correct medication, dose, and directions for use. Review of the electronic medical record for R14 revealed pertinent diagnoses of but not limited to hypertensive chronic kidney disease, essential primary hypertension,…

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, record reviews, and review of the facility's policies titled, Capillary Blood Sampling (Finger Stick Blood Sugar), Cleaning and Disinfection of Resident-Care Items and Equipment, and Infection Prevention and Control, the facility failed to ensure infection control practices were followed for four of 39 residents (R) (R44, R20, R14, and R33). Specifically, the facility failed to ensure the glucometer was cleaned per the user instruction manual for R44; failed to ensure shared resident equipment was sanitized between uses and failed to ensure staff followed Enhanced Barrier Precaution (EBP) guidelines during wound care for R33. Findings included: Review of facility's policy titled, Capillary Blood Sampling (Fingerstick Blood Sugar), reviewed and updated March 2014, revealed under Procedural Guidelines, Our facility follows the manufacturers recommended guidelines in using their machine for FSBS. Follow current standards of care regulations related to handling potentially infectious materials including but not limited to standard precautions,…

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 observation, staff interviews, and review of the facility policy titled, Food Receiving and Storage, the facility failed to label, and date opened food items in the dry storage area and failed to date opened bulk food items. The facility census was 62 and all residents consumed an oral diet. Findings include: Review of the facility policy titled Food Receiving and Storage revealed dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date). All food stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). Observation on 7/21/2023 at 9:00 a.m. of the dry storage area revealed a large clear plastic rectangle bin that contained a large open bag of Egg Noodles with no label or date also in this bin was an open bag of 10-inchch tortilla shells had no open date. No unattached food labels were noted loose on the bottom of bin. In separate large clear plastic rectangle bin was an open bag of Devil Food Cake Mix with no date. No unattached food labels were noted loose on the bottom of the bin. During 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, staff interviews, review of pharmacy guidelines, review of latanoprost ophthalmic solutions manufacturer packet insert, review of the Trelegy Ellipta oral inhalant manufacturer packet insert; and review of the facility policies title, Medication Storage in the Care Center, and Metered Dose Inhalers (MDI), the facility failed to ensure drugs and biologicals used in the facility were labeled and stored properly and in accordance with manufacturer's recommendations on two of three medication carts (A Wing cart and B Wing cart). Findings include: Review of the policy titled, Medication Storage in the Care Center dated October 2017 revealed the intent of medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The Procedural Guidelines section line numbered 13 revealed medications requiring refrigeration or temperature between 2 degrees Celsius (C) (36 degrees Fahrenheit (F)) and 8 degrees C (46 degrees F) are kept in a refrigerator with a thermometer to allow temperature monitoring.…

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 interviews, record review, and review of the facility policy titled, Abuse Prevention Program, the facility failed to report an allegation of abuse for one resident (R #50) of 13 residents on the Memory Care Unit. Findings include: Review of the policy titled Abuse Prevention Program, last reviewed and updated October 2016, revealed the following: D. Reporting: 1) Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse including injuries of unknow source/origin and misappropriation of resident property the incident will be immediately reported. a. The Administrator or designee will immediately notify HFR Complaint Investigation Intake and Referral Unit and resident representative of the incident and the pending investigation. The Ombudsman will also be notified as appropriate. The Administrator or designee will direct the investigation. c. The initial report of the incident will be faxed or emailed immediately but no more than 2 hours of abuse or an incident that results in serious injury or within 24 hours where there is no abuse or…

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 staff interviews, record reviews, and review of the facility policy titled, Controlled Drug Accountability and Reconciliation the facility failed to maintain accurate records on controlled substances on one of three medication carts (A Wing cart). Findings include: Review of the policy titled, Controlled Drug Accountability and Reconciliation dated October 2017 revealed the intent was to establish a method for accountability and reconciliation of controlled medications. Controlled medications should be tracked form the time they are received in the center through administration, discontinuation, discharge, or destruction. The Procedural Guidelines section lines numbered 2: During the next shift change, both the on-coming and off-going nurses should check the delivery sheet and verify that each controlled medication delivered has been placed in the appropriate place on the medication cart and documented on the Controlled Medication Audit (CMA) form. 4: Audits should be performed weekly, ideally by the Director of Nursing (DON), Assistant Director of Nursing (ADON), Nurse…

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 review, staff interview, and review of the facility policy titled, Automatic Stop Orders, the facility failed to ensure a stop date was implemented, not to exceed 14 days for psychotropic medications for two residents (R) (R#9, R#50) of six residents reviewed for unnecessary medications. Specifically, the facility failed to ensure a stop date was implemented for antianxiety medication ordered as needed (PRN) for R#9 and R#50. 1.Findings are: A review of the facility policy Automatic Stop Orders, updated 10/2017, revealed as needed (PRN) psychotropics had a 14-day stop date. Additionally, the prescribed may specify a duration longer than 14 days for PRN psychotropic medications, but the prescriber must include a clinical rationale in the permanent medical record. PRN antipsychotics could not be renewed for longer than 14 days without a direct evaluation of the patient by the prescriber. A review of the physician (MD) orders revealed R#9 was prescribed one Xanax 0.5 Milligram (mg) tablet by mouth every 6 hours as needed (PRN) on 5/30/2023. The order had no end date. 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.