Inspection Reports for Magnolia Crossing Nursing and Rehabilitation Center

The facility failed to ensure a resident received appropriate treatment and care according to professional standards and the resident's care plan. Specifically, staff did not perform an assessment when the resident reported difficulty breathing, which could lead to delayed treatment or worsening condition.

The complaint involved an allegation that CNA A hit Resident #1 on the right eye on an unknown date. Resident #1's family member reported the allegation to Nurse A on 08/16/25, but Nurse A failed to report it to the Administrator as required. Interviews with Resident #1, family member, Nurse A, CNA A, CNA B, the Director of Nursing, and the Administrator confirmed the failure to report and delayed investigation. Staff involved were suspended and in-servicing planned.

The facility failed to implement policies and procedures to prevent abuse and failed to timely report an alleged abuse incident to the Administrator. Nurse A did not report the allegation made by Resident #1's family member on 08/16/25. Staff members involved were suspended pending investigation.

The facility failed to treat residents with respect and dignity, failed to obtain proper consent and assessments for bed rail use, and failed to maintain proper infection control practices including hand hygiene and use of personal protective equipment. These failures posed risks of diminished quality of life, injury, infection, and cross-contamination to residents.

The complaint investigation focused on allegations that residents were not treated with dignity, bed rails were used without proper assessment and consent, and dental care needs were not addressed timely. The investigation included interviews, record reviews, and video observations confirming these issues.

The facility failed to treat residents with respect and dignity, failed to obtain proper assessments, orders, and consents for bed rail use, and failed to assist a resident in obtaining emergency dental care for tooth pain. These failures posed risks of diminished quality of life, injury, and health decline.

The facility failed to provide a safe, clean environment for Resident #1 by not changing linens for 8 days, resulting in dried fecal matter and food crumbs on the bed linens. Additionally, Resident #2 did not consistently receive scheduled bed baths on Tuesdays, Thursdays, and Saturdays, which could cause skin breakdown, discomfort, and dignity issues. Interviews with residents, family members, CNAs, nursing staff, and administrators confirmed these deficiencies and highlighted communication and documentation issues.

The complaint investigation was substantiated by video evidence showing the CNA asleep while feeding Resident #1, who coughed during the meal. Interviews with staff, residents, and family members confirmed the incident and concerns about supervision. The facility acknowledged staffing shortages and planned disciplinary and corrective actions.

The facility failed to ensure adequate supervision to prevent accidents for one resident who required feeding assistance. A CNA fell asleep while feeding Resident #1, who began coughing, potentially risking aspiration and other complications. Video evidence confirmed the CNA was asleep during feeding, and interviews revealed staffing challenges and lack of proper supervision.

The complaint investigation revealed that Resident #1's right hip fracture discovered on 10/27/2023 was not reported to the state agency until 10/30/2023, three days late. Interviews and record reviews confirmed the delay in reporting and the facility's failure to follow abuse, neglect, and injury reporting policies. Resident #1 was cognitively impaired and had a history of transferring without assistance. The facility's abuse coordinator reported the incident via email due to technical issues with the reporting portal.

The facility failed to report Resident #1's right hip fracture to the state agency within the required timeframe, reporting it three days late. Resident #1 had dementia and was at risk for fractures due to osteoarthritis and poor safety awareness. The facility also failed to incorporate PASRR level II recommendations and submit authorization for habilitative services for four residents, placing them at risk for not receiving timely specialized services.

The complaint investigation found that the DSS left work early due to symptoms but did not report them properly and returned to work after a negative COVID-19 test without a required confirmatory second test. The DSS later tested positive along with 9 residents, exposing others to COVID-19. The facility did not follow its own COVID-19 Exposure Management Plan requiring a second test after a negative antigen test.

The facility failed to maintain an effective infection prevention and control program by not following policy requiring a secondary COVID-19 test after a negative test for a direct care staff (DSS) member, which placed residents at risk of COVID-19 exposure. The DSS worked while symptomatic and tested positive after initially testing negative without a confirmatory second test.

The facility failed to employ a qualified full-time social worker for its 128-bed capacity, placing residents at risk of unmet social service needs. The Administrator was temporarily handling social work responsibilities after the former Social Worker resigned.

The facility was found to have multiple deficiencies including restricting residents' visitation hours contrary to policy, failure to properly label enteral feeding bags, delayed medication orders resulting in missed doses, storage of expired medications, lack of a full-time qualified social worker for a facility with more than 120 beds, and inadequate infection prevention practices related to medication handling.