Inspection Report Summary
The most recent inspection on November 22, 2021, identified several deficiencies related to employee health screenings, medication administration records, incident reporting, background checks, and staff competency documentation. Earlier inspections showed a pattern of issues with medication administration records, staff training and competency, and documentation of resident care plans and legal documents. Complaint investigations prior to this were mostly unsubstantiated, with one substantiated complaint leading to the November 2021 findings. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history indicates recurring documentation and staff training issues without a clear pattern of improvement or worsening over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
18% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 6
Nov 22, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00218829 and to conduct the compliance inspection.
Findings
The facility failed to ensure that employees received required tuberculosis screenings and physical exams, failed to update medication administration records for residents, failed to have clear medication orders for insulin dosage increases, failed to report a serious incident involving a resident's broken arm, failed to conduct required fingerprint criminal background checks for staff, and failed to maintain annual skills competency checklists for staff.
Complaint Details
The visit was complaint-related, investigating intake #GA00218829. The complaint involved failures in employee health screenings, medication administration documentation, incident reporting, background checks, and staff competency documentation.
Severity Breakdown
D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility failed to ensure each employee received a tuberculosis screening and physical examination within 12 months prior to employment for 1 of 5 sampled staff (Staff E). | D |
| Staff failed to update the medication assistance record (MAR) each time medication was offered or taken for 2 of 4 residents (Resident #2 and Resident #4). | D |
| Facility failed to ensure clear physician or advanced practice nurse orders for self-administered medications for 1 of 4 residents (Resident #4). | D |
| Facility failed to report to the Department a serious incident involving a resident's broken arm for 1 of 4 residents (Resident #3). | D |
| Facility failed to ensure direct care staff hired after October 1, 2019 had required fingerprint criminal background checks for 1 of 5 sampled staff (Staff E). | D |
| Facility failed to maintain written evidence of satisfactory annual skills competency determinations for 2 of 5 staff (Staff C and Staff D). | D |
Report Facts
Number of sampled staff: 5
Number of residents reviewed for medication assistance: 4
Number of residents with medication MAR issues: 2
Number of residents with medication order issues: 1
Number of residents with unreported serious incident: 1
Number of staff lacking annual skills competency documentation: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Failed to have physical exam, fingerprint background check, and tuberculosis screening | |
| Staff B | Interviewed regarding missing physical exam and incident reporting | |
| Staff D | Interviewed regarding medication administration record issues and insulin order clarification | |
| Staff A | Interviewed regarding resident incident and medication administration | |
| Staff C | Lacked updated annual skills competency checklist |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 11, 2021
Visit Reason
The purpose of this survey was to investigate complaint #GA00211070, with the investigation starting on 2021-01-29 and completing on 2021-02-12.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint #GA00211070 was conducted with no rule violations found.
Inspection Report
Monitoring
Deficiencies: 0
Apr 7, 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
Annual Inspection
Deficiencies: 7
Jan 29, 2018
Visit Reason
The purpose of this visit was to conduct an annual inspection of Magnolia Estates of Winder.
Findings
The facility failed to update the Medication Assistance Record (MAR) each time medication was offered or taken for 5 of 6 residents reviewed. Additionally, the facility failed to ensure written informed consent for proxy caregivers, failed to develop written plans of care by licensed healthcare professionals for some residents, and failed to provide adequate training and evaluation for proxy caregivers.
Severity Breakdown
SS= D: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to update the Medication Assistance Record (MAR) each time medication was offered or taken for 5 of 6 residents. | SS= D |
| Failure to ensure written informed consent permitting proxy caregiver to provide health maintenance activities for 1 of 6 sampled residents. | SS= D |
| Failure to ensure a written plan of care was developed by a licensed healthcare professional for 2 of 6 sampled residents. | SS= D |
| Failure to employ a written training curricula developed by licensed healthcare professionals ensuring proxy caregivers demonstrate required health maintenance activities correctly and safely for 1 of 4 sampled staff. | SS= D |
| Failure to include satisfactory and independent completion of required skills competency checklists before proxy caregivers perform health maintenance activities for 1 of 4 sampled staff. | SS= D |
| Failure to provide satisfactory evidence of routine evaluations of continued skills competencies by a licensed healthcare professional at least annually for 3 of 4 sampled staff. | SS= D |
| Failure to provide documentation reflecting training of proxy caregivers in accordance with medication administration training curriculum for 1 of 4 sampled staff. | SS= D |
Report Facts
Residents with MAR deficiencies: 5
Sampled residents: 6
Sampled proxy caregiver staff: 4
Sampled residents without written plan of care: 2
Sampled residents without informed consent: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Proxy caregiver staff lacking documented training and competency completion; administered medications to Residents #4, #5, and #6. | |
| Staff A | Proxy caregiver staff lacking routine evaluation of continued skills competency. | |
| Staff B | Proxy caregiver staff lacking routine evaluation of continued skills competency; interviewed regarding MAR signing issues. | |
| Staff D | Proxy caregiver staff lacking routine evaluation of continued skills competency; involved in training and interview discussions. | |
| AA | Proxy caregiver who trained Staff C. |
Inspection Report
Annual Inspection
Deficiencies: 3
Jan 31, 2017
Visit Reason
The purpose of this visit was to conduct an annual inspection of Magnolia Estates of Winder.
Findings
The facility failed to complete resident needs assessments at admission for 3 of 6 residents, failed to maintain inventories of personal items for 2 of 6 residents, and failed to include copies of living wills or advance directives for 5 of 6 residents.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to complete a resident needs assessment at the time of admission for 3 of 6 residents sampled (Resident #4, Resident #5, Resident #6). | SS= D |
| Failed to maintain an inventory of personal items brought to the home by residents for 2 of 6 sampled residents (Resident #2 and Resident #6). | SS= D |
| Failed to include a copy of a living will and/or power of attorney for health care or a copy of the Georgia advance directive for health care for 5 of 6 residents (Resident #1, Resident #2, Resident #3, Resident #5, Resident #6). | SS= D |
Report Facts
Residents sampled: 6
Residents missing needs assessment: 3
Residents missing personal inventory: 2
Residents missing advance directive: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed and stated unawareness of missing paperwork related to deficiencies |
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