Magnolia Manor Nursing and Rehab Ctr, LLC

Based on observations and interviews, the facility failed to maintain an effective pest control program by failing to ensure the facility was free of pest and insects. The deficient practice had the potential to affect 89 residents who resided in the facility. Findings:Observation on 04/30/2026 at 8:30 a.m. with S3Housekeeping of Resident #1 and #3's room revealed a live roach crawling on the wall, on the top of Resident #1's refrigerator, and underneath the desk-style phone on top of the refrigerator. During an interview on 04/30/2026 at 8:30 a.m. S3Housekeeping reported she saw one roach yesterday in Resident #1 and #3's room. During an interview on 04/30/2026 at 8:40 a.m. S2Maintenance reported S4Certified Nurse Aide just made him aware yesterday afternoon about a roach on the wall in Resident #1 and #3's room.Observation on 04/30/2026 at 8:45 a.m. with S2Maintenance of Resident #1 and #3's room revealed roach feces and dead roach carcasses on the top of Resident #1's personal refrigerator. Further observation revealed when S2Maintenance picked up the phone and a book laying on…

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, observation and interview, the facility failed to ensure proper infection control techniques were practiced to prevent urinary tract infection for 1 (#23) of 1 resident reviewed for indwelling catheter.Findings:Review of the facility's Catheter Management undated policy revealed in part:Policy: Catheter management is the routine care administered when an indwelling catheter is in place. This routine care protects the resident from infection, injury, and promotes comfort.b. Watch for kinking in the tubing to can interfere with patency and free flow of urine. Never allow the bag or tubing to touch the floor. Review of Resident #23's medical record revealed an admit date of 04/19/2022 with diagnoses including neurogenic bladder and Type 2 Diabetes Mellitus.Review of Resident #23's current comprehensive care plan revealed Resident #23 had a suprapubic catheter related to a diagnosis of urinary retention.An observation on 03/02/2026 at 9:25 a.m., revealed Resident #23 was self-propelling down the hall in a wheelchair. Further observation revealed Resident #23's…

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, observation, and interviews, the provider failed to ensure respiratory care was provided with professional standards of practice for 1 (#84) of 1 resident reviewed for respiratory care. Findings: Review of the provider's undated Oxygen Administration (concentrator or tank) policy included:Humidifier bottles, cannulas, and oxygen tubing will be changed at least once weekly and dated. Concentrator filter should be cleaned weekly or as needed as well. When not in use, cannula or mask should be placed in a plastic bag. Purpose:To administer high-purity oxygen for the treatment of disease or emergency conditions through oxygen concentrator or tank. Review of Resident #84's medical record revealed the following, in part: Resident #84 was admitted to the provider on 02/14/2026 with diagnoses including in part: chronic obstructive pulmonary disease, tobacco use, nonspecific abnormal finding of lung field, centrilobular emphysema, chronic respiratory failure with hypoxia, and shortness of breath. Review of Resident #84's physician orders for March 2026 included:Oxygen…

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, observations, and interviews, the facility failed to ensure medications were stored properly for 2 (#21 and #68) of 4 residents reviewed for accidents. Findings:Review of the facility's Self-Administration of Medication policy (undated) revealed in part:It is the policy of this facility that each resident has the right to self-administer medications, but is the responsibility of the interdisciplinary team to determine that it is safe prior to the resident exercising that right.If the right is granted, a specific order to self-administer must be obtained which includes how, when and for what reason the medication can be used.Facility personnel must assure safety of bedside storage of medication. A locked box may be necessary in some instances. Resident #21Review of Resident #21's medical record revealed an admit date of 10/02/2025 with diagnoses including in part chronic kidney disease, end stage renal disease and postmenopausal atrophic vaginitis. Review of Resident #21's Quarterly MDS…

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, observation and interview, the facility failed to maintain professional standards for food service safety by failing to ensure frozen food items were stored in a sealed container. Findings:Review of the facility's Storage of Frozen Food policy with a revision date of 12/2012 revealed in part:Policy: The facility ensures the quality and safety of frozen food through accepted storage practices.Procedure:4. Frozen food is stored in the original package.5. Food taken out of original containers is put in a clean, sanitized container with a tight fitting. No food is left uncovered. An observation of the walk-in freezer on 03/02/2026 at 8:00 a.m. revealed frozen broccoli, frozen egg rolls and frozen waffles stored in unsealed plastic bags and open to air. During an interview on 03/02/2026 at 8:00 a.m., S3Dietary Manager acknowledged the frozen broccoli, frozen egg rolls and frozen waffles should have been stored in a sealed bag in the freezer and were not.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview the facility failed to inform a resident's responsible party of a resident's change in condition for 1 (#1) of 3 (#1, #2, #3) sampled residents. The facility failed to notify Resident #1's responsible party of the initiation of a medication. Findings: Review of Resident #1's medical record revealed an admit date of 08/09/2024 and a re-admission date of 01/15/2026 with diagnoses of but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, bipolar II disorder, type 2 diabetes mellitus without complications, schizoaffective disorder bipolar type, generalized anxiety disorder, unspecified convulsions, unspecified conjunctivitis, contracture to left hip, and pressure ulcer sacral region. Review of Resident #1 Minimum Data Set, dated [DATE] revealed a BIMS (Brief Interview Mental Status) score of 9 indicating moderately impaired cognition. Review of Resident #1's June 2025 Physician's Orders revealed and order for Depakote oral…

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 surveillance video and interviews, the facility failed to treat and care for each resident in a manner that promotes dignity and enhancement of his or her quality of life for 1 (#1) resident of 3 (#1, #2, #3) residents reviewed for abuse. S6 CNA (Certified Nurse Assistant) provided care to Resident #1 in a hurried manner, spoke to Resident #1 in a disrespectful manner and talked to other staff about Resident #1. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 03/31/2025. It was determined to be a Past Noncompliance Citation. Findings: Review of Resident #1's room surveillance video on 04/01/2025 at 3:00 p.m. provided by Resident #1's family memeber's cellphone with Resident #1's family member who was present revealed: Surveillance video clip started on 02/12/2025 at 2:04 p.m. with a duration of about 5 minutes. At the start of the video S6 CNA walked passed the camera and stated; Just nothing else better to do; Just nothing else better to do. S8 CNA moved the overbed table and attempted to try to remove 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 record reviews, surveillance video review and interviews, the facility failed to implement policies and procedures to ensure an allegation of abuse was reported to administration in a timely manner per the facility's policy for 1 (#1) of 3 (#1, #2, #3) residents reviewed for abuse. S7 CNA (Certified Nurse Assistant) failed to recognize and report physical and verbal abuse during incontinent care provided by S6 CNA. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 03/31/2025. It was determined to be a Past Noncompliance Citation. Findings: Review of facility's Abuse/Neglect Policy with a revision date of 03/20/2025 revealed in part: Purpose: The purpose of the Abuse/Neglect policy is to comply with the seven-step approach to abuse and neglect detection and prevention. Policy: It is the policy of the facility that each resident will be free from abuse. This facility will not condone any form of resident abuse. Each resident residing in this facility has the right to be free from verbal, sexual, mental and…

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 and interviews, the facility failed to ensure residents were free from unnecessary medications for 1 (#52) out of 5 (#15, #20, #26, #52, #88) residents reviewed for unnecessary meds. The facility failed to monitor Resident #52's edema while receiving a diuretic. Findings: Review of Resident #52's medical records revealed admit date of 12/01/2023 with the following diagnoses, including in part: chronic pulmonary edema and chronic diastolic (congestive) heart failure. Review of Resident #52's Physician's Orders revealed an order dated 08/01/2024 for Furosemide Tablet 40mg (milligram). Give 1 tablet by mouth two times a day. Review of Resident #52's November 2024 Medication Administration Record (MAR) failed to reveal monitoring for edema. During an interview on 12/04/2024 at 10:32 a.m. S4 LPN (Licensed Practical Nurse) confirmed Resident #52 was receiving a diuretic. S4 LPN further reported she was unable to provide documentation Resident #52's edema was monitored. During an interview on 12/04/2024 at 10:45 a.m. S2 Director of Nursing acknowledged Resident #52…

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, observations and interview, the facility failed to provide residents necessary respiratory care and services in accordance with accepted professional standards of practice for 1 (#52) out of 1 (#52) resident reviewed for respiratory services. The facility failed to clean Resident #52's oxygen concentrator filter weekly and as needed. Findings: Review of Facility's oxygen Tanks: Administration (concentrator or tank) Policy (no date) revealed: Policy: Humidifier bottles, cannulas and O2 (oxygen) tubing will be changed at least once weekly and dated. Concentrator filter should be cleaned weekly or as needed as well . Review of Resident #52's medical records revealed admit date of 12/01/2023 with the following diagnoses, including in part: pneumonia/unspecified organism (onset 11/29/2024), acute respiratory failure with hypoxia, chronic obstructive pulmonary disease/unspecified, chronic pulmonary edema, dependence on supplemental oxygen and chronic diastolic (congestive) heart failure. Review of Resident #52's Physician's Orders revealed an order dated…

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.