Inspection Reports for Magnolia Estates
68 COLLEGE AVENUE, ELBERTON, GA, 30635
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 19, 2024, identified deficiencies related to incomplete physical examinations, medication record updates, and failure to report a resident’s death. Earlier inspections showed a pattern of issues including staff training, medication management, resident safety, and infection control, with some complaints substantiated and others not. Inspectors cited recurring themes around documentation accuracy, staff preparedness, and timely reporting of incidents. Complaint investigations were mostly unsubstantiated except for a few substantiated cases involving resident care and infection control during a COVID-19 outbreak. The facility’s inspection history shows ongoing challenges with compliance in several areas, with no clear pattern of consistent improvement or worsening over time.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
2.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
49% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 17, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA50000240.
Complaint Details
Investigation of intake #GA50000240 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 24, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00251116.
Complaint Details
Investigation of intake #GA00251116 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 19, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00249986 and conduct the compliance inspection.
Complaint Details
The visit was complaint-related based on intake #GA00249986. The complaint involved failure to obtain required physical examinations, failure to update medication records, and failure to report a resident's death.
Findings
The facility failed to obtain complete physical examinations on the Department's form for 4 of 8 sampled residents, failed to update the Medication Assistance Record (MAR) for 2 of 8 residents, and failed to report an accidental or unanticipated death of a resident to the Department.
Deficiencies (3)
Failed to obtain a physical examination on the Department's form prior to admission and completed in its entirety for 4 of 8 sampled residents.
Failed to ensure the Medication Assistance Record (MAR) was updated each time the medication was offered or taken for 2 of 8 sampled residents.
Failed to report any accidental or unanticipated death of a resident to the Department for 1 of 8 residents.
Report Facts
Residents sampled: 8
Residents with physical exam deficiencies: 4
Residents with MAR deficiencies: 2
Resident death not reported: 1
Date of resident death: Aug 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed regarding missing physical exams for Resident #2 and Resident #4 and medication administration record issues for Resident #2 | |
| Staff K | Interviewed regarding medication administration record issues for Resident #3 | |
| Staff A | Interviewed regarding unreported death of Resident #4 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 17, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00247324.
Complaint Details
Investigation of intake #GA00247324 with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Nov 2, 2023
Visit Reason
The purpose of this visit was to investigate complaint intakes GA00240141 and GA00240205 and conduct the compliance inspection.
Complaint Details
The visit was complaint-related, investigating intakes GA00240141 and GA00240205. The findings included substantiated deficiencies related to staff training, aging in place criteria, medication management, and resident restraints.
Findings
The facility was found deficient in multiple areas including failure to provide required work-related training for staff, failure to meet aging in place criteria for non-ambulatory residents related to fire drills and staffing, failure to timely obtain medication refills causing interruptions in routine dosing, and failure to ensure residents were free from physical restraints.
Deficiencies (5)
Facility failed to ensure that any person working in the home received work-related training within the first sixty days of employment, including current certification in emergency first aid for 1 of 6 sampled staff (Staff E).
Facility failed to ensure that medical and social needs and characteristics of the resident population training was completed for 3 of 6 staff (Staff C, Staff D, and Staff E).
Facility failed to meet aging in place criteria for non-ambulatory residents related to fire drill performance, frequency, and staffing for 3 of 5 residents (Resident #2, Resident #3, and Resident #4).
Facility failed to ensure timely refills of prescribed medications to avoid interruption in routine dosing for 1 of 5 sampled residents (Resident #5).
Facility failed to ensure that each resident was free of physical restraints for 2 of 5 residents (Resident #2 and Resident #4) who were observed with full size bed rails raised.
Report Facts
Sampled staff: 6
Non-ambulatory residents: 3
Sampled residents: 5
Fire drills: 6
Evacuation time (minutes): 16
Evacuation time (minutes): 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Named in deficiency for lack of first aid certification and incomplete training | |
| Staff A | Interviewed and aware of multiple findings including training and fire drill deficiencies | |
| Staff C | Named in medication refill deficiency and incomplete training | |
| BB | Interviewed regarding Resident #3's decline and bedbound status |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 26, 2022
Visit Reason
The purpose of this visit was to conduct the compliance inspection and investigate intake #GA00227101. An on-site visit was made to the facility on 10/26/22 and the investigation was completed on 10/28/22.
Complaint Details
Investigation was conducted related to intake #GA00227101. The deficiency was substantiated based on record review and interview.
Findings
The facility failed to ensure that each employee received a tuberculosis screening and a physical examination within 12 months prior to employment for 1 of 5 staff (Staff C). The file for Staff C, hired 10/10/22, showed no results of a TB screening and physical examination within 12 months prior to employment.
Deficiencies (1)
Facility failed to ensure each employee received a tuberculosis screening and a physical examination within 12 months prior to employment for 1 of 5 staff (Staff C).
Report Facts
Staff reviewed: 5
Staff non-compliant: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Staff member without required TB screening and physical examination within 12 months prior to employment | |
| Staff A | Interviewed staff who stated they thought there was a 30-day period upon hire to complete PE/TB |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 2, 2021
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00212110 and #GA00212139 with an onsite visit made on 3/2/2021 and the investigation completed on 3/29/2021.
Complaint Details
Investigation was triggered by complaint intakes #GA00212110 and #GA00212139. Resident #2 was found to have been sent to the hospital dirty and wet with excoriated areas on the scrotum. Staffing shortages and multiple emergencies on the day contributed to the failure to provide adequate care. Resident #1 reported the issue but is now deceased. Interviews with multiple staff confirmed the hectic conditions and staffing challenges on the day in question.
Findings
The facility failed to ensure sufficient staff time to keep residents comfortable and clean, specifically for Resident #2 who was sent to the hospital dirty and wet. Staffing shortages and multiple emergencies on 11/4/2020 contributed to inadequate care.
Deficiencies (1)
Facility failed to ensure sufficient staff time so that each resident was kept comfortable and clean for 1 of 3 residents (Resident #2).
Report Facts
Date of hospital arrival: Nov 4, 2020
Staff scheduled: 1
Staff usually on second floor: 3
Staff present on second floor: 2
Staff needed to assist Resident #1: 5
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Date: Nov 4, 2020
Visit Reason
The investigation was conducted to investigate complaint #GA00209411 with an on-site visit on 11/4/2020 and completed on 11/30/2020.
Complaint Details
Investigation of complaint #GA00209411 regarding COVID-19 outbreak and infection control failures. The complaint was substantiated with findings of inadequate PPE, lack of testing, and staff working while positive and asymptomatic.
Findings
The facility failed to use an effective infection control program to minimize the spread of infections during a COVID-19 outbreak. Multiple residents and staff tested positive, with several hospitalizations and deaths, and the facility lacked personal protective equipment and testing prior to the outbreak.
Deficiencies (1)
Failed to use an effective infection control program including responding to disease outbreaks to minimize the spread of infections.
Report Facts
Resident census: 38
Residents diagnosed with COVID-19: 33
Resident deaths: 4
Residents hospitalized: 7
Facility resident census: 25
Staff census: 38
Staff positive for COVID-19: 22
Staff hospitalized: 3
Staff in isolation: 10
Residents tested positive on 10/31/20: 20
Residents positive on 11/16/20: 28
Staff positive on 11/16/20: 17
Inspection Report
Monitoring
Deficiencies: 0
Date: Apr 6, 2020
Visit Reason
The purpose of this review is to monitor COVID-19 cases and assess infection control process.
Findings
The report focuses on monitoring COVID-19 cases and assessing the infection control process at the facility.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 6, 2019
Visit Reason
The purpose of this visit was to conduct a follow up to the 10/25/18 compliance inspection and complaint investigation.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Oct 24, 2018
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate complaint #GA00192170. The inspection began on 10/24/18 and was completed on 10/25/18.
Complaint Details
The investigation was triggered by complaint #GA00192170 regarding Resident #1 who left the building unattended, fell outside unhurt, and the facility failed to ensure safety devices were operable, failed to notify the resident's representative timely, and failed to report the incident to the Department within 24 hours.
Findings
The facility failed to ensure that safety devices to protect residents at risk of wandering were operable, failed to provide adequate care and services to Resident #1, failed to notify the resident's representative of an incident, and failed to report a serious incident to the Department within 24 hours.
Deficiencies (4)
Safety devices used to protect residents at risk of wandering were either turned off or not operable.
Failed to ensure each resident received adequate and appropriate care and services in compliance with federal and state law for Resident #1.
Failed to notify the resident's representative of an incident involving Resident #1.
Failed to report a serious incident involving Resident #1 to the Department within 24 hours.
Report Facts
Number of sampled residents: 7
Incident date: Aug 10, 2018
Incident report notification time: 900
Staff work schedule: 1000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Reported finding Resident #1 lying outside and was working during the incident | |
| Staff H | Scheduled staff on duty during incident, terminated for not being cut out for the job | |
| Staff A | Reported that Staff H was terminated and usually notifies family of incidents | |
| Staff B | Unaware that incident needed to be reported to the Department | |
| AA | Resident representative who was notified late about the incident | |
| Staff F | Notified Staff G about Resident #1 lying outside |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 16, 2017
Visit Reason
The purpose of this survey was to conduct a paperwork follow-up to the 2017-03-16 inspection.
Findings
Based on a review of documentation submitted by the facility, the violations cited on the previous inspection have been corrected.
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Mar 16, 2017
Visit Reason
The purpose of this visit was to conduct an annual inspection of Magnolia Estates.
Findings
The facility failed to have updated work performance reviews for unlicensed staff administering medications, incomplete Medication Assistance Records (MAR) lacking allergies and provider contact information, failure to update MARs when medications were given or refused, lack of written informed consents for proxy caregiver services, and absence of written plans of care for proxy caregiver services for residents.
Deficiencies (5)
Failed to have work performance reviews (skills competency checklists) for 2 unlicensed staff administering medications to 2 residents.
Medication Assistance Record (MAR) lacked known allergies, health care provider contact, and specific medication directions for 1 resident.
Staff failed to update MAR each time medication was offered or taken for 2 residents.
Failed to have written informed consent for proxy caregiver services for 2 residents.
Failed to have a written plan of care for proxy caregiver services for 2 residents.
Report Facts
Residents with missing work performance reviews: 2
Residents with incomplete MAR: 1
Residents with MAR not updated: 2
Residents without written informed consent: 2
Residents without written plan of care for proxy caregiver services: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in findings related to medication administration and MAR documentation | |
| Staff F | Named in findings related to medication administration and MAR documentation | |
| Staff G | Named in findings related to proxy caregiver informed consent and plan of care |
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