Inspection Reports for Magnolia Healthcare and Rehabilitation Center
1410 Trotwood Ave, Columbia, TN, 38401
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
75% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 8
Date: Jun 15, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including care planning, advanced directives, baseline care plans, medication administration, fall prevention, nutrition, menu planning, and infection control.
Findings
The facility was found deficient in multiple areas including failure to involve residents and direct care staff in care planning, failure to provide information on advanced directives, failure to develop baseline care plans within 48 hours of admission, failure to administer medications as ordered, failure to implement fall prevention interventions, failure to accurately assess and monitor nutritional status, failure to provide alternative food and menu choices, and failure to maintain infection prevention practices including staff screening and hand hygiene.
Deficiencies (8)
Failed to ensure residents were involved in developing the Care Plan and failed to include direct care staff in the Interdisciplinary Care Planning for 3 of 3 sampled residents.
Failed to provide information regarding a resident's right to formulate an Advanced Directive for 16 of 27 sampled residents.
Failed to develop a Baseline Care Plan within 48 hours of admission for 3 of 19 sampled residents.
Failed to ensure medications were administered as ordered for 2 of 2 sampled residents.
Failed to ensure Care Plan interventions were followed to prevent falls for 1 of 1 sampled resident.
Failed to accurately assess the nutritional status and to follow the facility's policy for monitoring weights for 6 of 6 sampled residents.
Failed to ensure 6 of 16 sampled residents had alternative food and menu choices.
Failed to ensure practices to maintain the spread of infection were maintained when 14 of 67 staff members failed to complete COVID-19 screening prior to working and 3 of 4 nurses failed to perform hand hygiene during medication administration.
Report Facts
Residents reviewed for Advanced Directives: 27
Residents reviewed for Baseline Care Plan: 19
Residents reviewed for medication administration: 2
Residents reviewed for fall prevention: 1
Residents reviewed for nutrition: 6
Residents reviewed for menu choices: 16
Staff members failed COVID-19 screening: 14
Nurses failed hand hygiene: 3
Residents in facility: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Confirmed missing medication and inability to locate Hibiclens |
| Nurse Practitioner | Nurse Practitioner | Notified about missing medication doses and described medication ordering process |
| Interim Director of Nursing | Interim Director of Nursing | Confirmed multiple deficiencies including medication administration, infection control, and care planning |
| MDS Coordinator | Minimum Data Set Coordinator | Confirmed care plan and baseline care plan deficiencies |
| Social Service Assistant | Social Service Assistant | Interviewed about care plan conference scheduling and team involvement |
| Dietary Manager | Dietary Manager | Confirmed lack of food preference documentation and plans for improvement |
| Interim Assistant Director of Nursing | Interim Assistant Director of Nursing | Observed fall prevention interventions missing and confirmed care plan adherence |
Inspection Report
Routine
Census: 73
Deficiencies: 5
Date: Aug 1, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning, accident hazards, medication storage, food safety, and infection control at Magnolia Healthcare and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to involve patient representatives in care planning, failure to revise care plans to reflect current conditions, presence of accident hazards, improper medication storage, unsanitary food storage and preparation conditions, and inadequate infection prevention practices during wound care.
Deficiencies (5)
Failure to ensure the patient representative was involved in developing the care plan and making decisions and failure to revise the care plan for 2 of 20 sampled residents.
Failure to ensure the environment was free of accident hazards as evidenced by an aerosol can and an unsecured razor in 1 of 51 resident rooms.
Failure to ensure medications were stored properly and safely in 1 of 6 medication storage areas.
Failure to ensure food was stored, prepared, and served under sanitary conditions including absence of hand washing supplies, improper handwashing, undated, unlabeled, and expired food items, carbon build up on pans and stove, lack of hair restraints, dirty kitchen and equipment, improper storage of utensils and food items, and incomplete dishmachine temperature logs.
Failure to ensure measures to prevent the potential spread of infection were followed by a nurse during wound care observations.
Report Facts
Residents receiving tray from kitchen: 72
Medication storage areas observed: 6
Resident rooms observed: 51
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Director | Interviewed regarding patient representative involvement in care planning | |
| Director of Nursing (DON) | Interviewed regarding care plan revisions, medication storage, accident hazards, and infection control practices | |
| Licensed Practical Nurse (LPN) #2 | Confirmed presence of aerosol spray can and razor in resident room | |
| Dietary Aide #1 | Observed with uncovered beard and mustache and improper food handling | |
| Dietary Aide #2 | Observed failing to wash hands before assisting with trays | |
| Registered Dietician (RD) | Interviewed regarding food safety and sanitation deficiencies | |
| Licensed Practical Nurse (LPN) #1 | Observed failing to follow infection prevention measures during wound care |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Sep 27, 2018
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity related to catheter care, timely and accurate resident assessments, comprehensive care planning, dialysis care and communication, medication administration errors, medication storage and labeling, food safety and sanitation, and infection prevention and control practices.
Deficiencies (10)
Failed to promote and maintain dignity for residents with indwelling urinary catheters by not providing dignity bags for catheter bags.
Failed to complete comprehensive resident assessments (MDS) within regulatory time frames for multiple residents.
Failed to update resident assessments at least once every 3 months for multiple residents.
Failed to ensure assessments accurately reflected resident status for dialysis for one resident.
Failed to develop and implement comprehensive care plans for residents reviewed.
Failed to ensure ongoing communication between facility and dialysis clinic for a resident receiving dialysis.
Medication error rate exceeded 5% with 3 errors out of 27 opportunities involving incorrect medication administration.
Failed to ensure medications were stored properly and safely in medication storage areas, including unlocked carts, unlabeled medications, and undated opened bottles.
Failed to ensure food was stored, prepared, and served under sanitary conditions including dirty kitchen floors and mats, undated/opened food items, dirty deep fryer, wet nesting of clean lids, staff not wearing hair/beard coverings, and improper thermometer sanitation.
Failed to ensure infection prevention practices including proper hand hygiene and proper cleaning of glucometer.
Report Facts
Residents affected: 2
Residents affected: 5
Residents affected: 13
Residents affected: 1
Residents affected: 4
Residents affected: 1
Medication errors: 3
Medication error rate: 11.11
Facility census: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON | Interviewed regarding catheter bag dignity, care plans, medication administration, dialysis communication, and glucometer cleaning |
| Director of Nursing | DON | Interviewed regarding dialysis assessment accuracy, medication storage, medication administration, and infection control |
| Licensed Practical Nurse #2 | LPN | Administered medication with error, observed for hand hygiene |
| Licensed Practical Nurse #3 | LPN | Administered medication with error, failed to clean glucometer properly |
| Licensed Practical Nurse #4 | LPN | Administered medication with error |
| Licensed Practical Nurse #5 | LPN | Interviewed regarding medication cart security and storage |
| Dietary Manager | DM | Interviewed regarding kitchen sanitation and food safety |
| Dietary Staff #1 | Dietary Staff | Observed without hair covering in kitchen |
| Dietary Staff #2 | Dietary Staff | Observed without beard covering in kitchen |
| Dietary Staff #3 | Dietary Staff | Observed without beard covering in kitchen |
| Registered Dietician | RD | Interviewed regarding kitchen sanitation and food safety |
| Registered Nurse #1 | RN | Observed for hand hygiene |
| Registered Nurse #2 | RN | Observed for hand hygiene |
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