Inspection Reports for Magnolia Manor of Midway

652 NORTH COASTAL HIGHWAY 17, MIDWAY, GA, 31320

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Inspection Report Summary

The most recent inspection on July 8, 2019, found no deficiencies despite a partially substantiated complaint. Earlier inspections showed a pattern of deficiencies primarily related to fire safety issues, including emergency lighting, fire suppression system inspections, and sprinkler coverage, as well as concerns with resident care planning and infection surveillance. Complaint investigations were mostly unsubstantiated, with one partially substantiated complaint that did not result in deficiencies. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to have made some improvements over time, correcting previously cited deficiencies, though fire safety issues recurred intermittently.

Deficiencies (last 3 years)

Deficiencies (over 3 years) 15.3 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

212% worse than Georgia average
Georgia average: 4.9 deficiencies/year

Deficiencies per year

12 9 6 3 0
2017
2018
2019

Census

Latest occupancy rate 114 residents

Based on a May 2019 inspection.

Census over time

80 100 120 140 160 180 Jan 2017 Feb 2018 Feb 2019 May 2019 May 2019

Inspection Report

Abbreviated Survey
Deficiencies: 0 Date: Jul 8, 2019

Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00197512 and GA00197560 on 7/1/19, 7/3/19, and 7/8/19.

Complaint Details
Complaint GA00197512 was partially substantiated; no deficiencies were cited.
Findings
Complaint GA00197512 was partially substantiated, but no deficiencies were cited during the survey.

Inspection Report

Follow-Up
Deficiencies: 0 Date: Jul 2, 2019

Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

Findings
The surveyor noted that all previously cited survey tags have been corrected.

Inspection Report

Follow-Up
Deficiencies: 1 Date: Jun 3, 2019

Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies, with the exception of emergency lighting issues.

Findings
The facility failed to maintain emergency lights in the medication rooms in Unit 100 and Unit 300 in operable condition as required by NFPA 101, which could place 25 residents at risk in the event of fire.

Deficiencies (1)
Facility failed to maintain emergency lights in the medication rooms in Unit 100 and 300 in operable condition as required by NFPA 101.
Report Facts
Residents at risk: 25 Emergency lights not operational: 2

Employees mentioned
NameTitleContext
Staff MConfirmed findings of non-operational emergency lights during the tour and staff interviews

Inspection Report

Abbreviated Survey
Census: 114 Deficiencies: 0 Date: May 31, 2019

Visit Reason
An abbreviated survey was conducted at Woodlands Health Care from May 21, 2019 through May 31, 2019 to investigate complaint GA00196929.

Complaint Details
Investigation of complaint GA00196929; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.

Report Facts
Resident census: 114

Inspection Report

Re-Inspection
Deficiencies: 3 Date: May 2, 2019

Visit Reason
A Revisit survey was conducted to verify correction of previously cited deficiencies.

Findings
The facility failed to maintain emergency lighting, was overdue for semi-annual inspection of the commercial kitchen hood fire suppression system, and lacked NFPA 13 compliant sprinkler coverage on an outside combustible covered patio, placing residents at risk in the event of fire.

Deficiencies (3)
Facility failed to maintain some emergency lights as required by NFPA 101, placing 25 residents at risk in the event of fire.
Facility failed to maintain the commercial kitchen hood fire suppression system; it was more than a year and a half past due its required semi-annual inspection.
Facility failed to provide NFPA 13 compliant sprinkler protection due to lack of fire sprinkler coverage on an outside combustible covered patio.
Report Facts
Residents at risk: 25 Dimensions of uncovered patio roof: 6.5 Dimensions of uncovered patio roof: 12

Employees mentioned
NameTitleContext
Staff M confirmed findings during the tour and interviews

Inspection Report

Abbreviated Survey
Deficiencies: 0 Date: May 2, 2019

Visit Reason
An abbreviated/partial survey was conducted at Woodlands Health Care investigating Complaint Number GA00196470.

Complaint Details
Complaint Number GA00196470 was investigated and found to be not substantiated.
Findings
The complaint was not substantiated and no deficiencies were cited during the survey.

Inspection Report

Re-Inspection
Census: 100 Deficiencies: 0 Date: May 2, 2019

Visit Reason
A revisit survey was conducted on May 1 through May 2, 2019 to verify correction of deficiencies cited in the Standard Survey of March 15, 2019.

Findings
All deficiencies cited as a result of the Standard Survey of March 15, 2019 were found to be corrected.

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Mar 27, 2019

Visit Reason
A complaint survey was conducted to investigate Complaint Intake number GA00194919 initiated on March 26, 2019 and concluded on March 27, 2019.

Complaint Details
Complaint Intake number GA00194919 was substantiated with no deficiencies.
Findings
The complaint was substantiated but no deficiencies were found during the investigation.

Inspection Report

Annual Inspection
Deficiencies: 2 Date: Mar 15, 2019

Visit Reason
The inspection was conducted as an annual survey to assess compliance with state regulations regarding nursing care, infection control, and other facility requirements.

Findings
The facility failed to ensure that resident care plans were revised appropriately following incidents, specifically for one resident (R#32) who experienced multiple falls. Additionally, the facility did not establish an effective infection surveillance system, lacking documentation and monitoring of infections.

Deficiencies (2)
Failure to revise resident care plans for one of 23 residents (R#32) after falls and changes in condition.
Failure to establish a surveillance system for identifying possible communicable diseases, risking infection transmission.
Report Facts
Residents affected: 1 Falls documented: 3

Employees mentioned
NameTitleContext
AdministratorInterviewed regarding care plan oversight and infection control documentation
Director of NursingDONInterviewed about infection prevention and care plan responsibilities
MDS CoordinatorResponsible for completing some care plans and interviewed about care plan updates

Inspection Report

Life Safety
Census: 112 Deficiencies: 10 Date: Feb 20, 2019

Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and emergency preparedness.

Findings
The facility was found not in substantial compliance with NFPA 101 Life Safety Code requirements, including deficiencies in emergency lighting, exit signage, kitchen fire suppression system inspection, fire alarm system installation and initiation, sprinkler system coverage, smoke barrier doors, fire drill documentation, and gas cylinder storage.

Deficiencies (10)
Emergency lighting in drug med rooms and kitchen did not operate during manual testing.
Exit signs failed to operate on battery backup during manual testing.
Commercial kitchen fire suppression system was more than a year and a half past due for semi-annual inspection.
Fire alarm system was undergoing replacement and not maintained as NFPA 72 compliant.
Fire alarm system manual pull stations were blue instead of required red color.
Facility failed to notify Georgia State Fire Marshal's Office after fire alarm system was out of service for more than 4 hours.
Lack of fire sprinkler coverage on outside combustible covered patio where spare oxygen cylinders are stored.
Two sets of corridor smoke barrier doors were held open by non-approved items and two other sets would not close fully, allowing passage of smoke.
Facility failed to provide documentation of required quarterly fire drills on every shift over the past 12 months.
Facility failed to segregate full and empty gas cylinders and four cylinders outside were freestanding and not secured.
Report Facts
Residents at risk due to emergency lighting deficiency: 25 Residents at risk due to exit signage deficiency: 50 Residents at risk due to fire alarm pull station deficiency: 30 Residents at risk due to gas cylinder storage deficiency: 12 Fire sprinkler patio roof dimensions: 6.5 Fire sprinkler patio roof dimensions: 12 Facility census: 112

Employees mentioned
NameTitleContext
Staff MConfirmed findings during facility tour and staff interviews

Inspection Report

Routine
Census: 112 Deficiencies: 6 Date: Feb 19, 2019

Visit Reason
A standard survey was conducted from February 19, 2019 through February 22, 2019, including investigation of a complaint intake number GA00194858 which was found to be unsubstantiated.

Complaint Details
Complaint Intake Number GA00194858 was investigated in conjunction with the standard survey and found to be unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to revise resident care plans after falls, failure to administer medications as ordered, inadequate fall investigations and prevention interventions, unsanitary food storage and equipment conditions, lack of infection surveillance, and absence of an antibiotic stewardship program.

Deficiencies (6)
Failure to revise resident care plans for one resident after falls and hospitalizations.
Failure to administer nystatin cream twice daily as ordered for one resident.
Failure to evaluate effectiveness of fall interventions and conduct root cause analysis for falls resulting in major injury for one resident.
Failure to ensure food was stored and prepared under sanitary conditions; ice machine leaking and stained with brown substance.
Failure to establish a surveillance system for identifying possible communicable diseases and infections.
Failure to establish an antibiotic stewardship program including antibiotic use protocols and monitoring system.
Report Facts
Resident census: 112 Nystatin cream administrations: 6 Fall Risk Assessment score: 12 Fall Risk Assessment score: 17 Sutures: 8

Employees mentioned
NameTitleContext
AdministratorInterviewed regarding care plan revisions, fall investigations, and infection control documentation
Director of Nursing (DON)Responsible for oversight of care plans, infection control, and antibiotic stewardship; interviewed regarding deficiencies
Assistant Director of Nursing (Assistant DON)Mentioned as responsible for oversight of care plans
Minimum Data Set (MDS) CoordinatorResponsible for some care plans; interviewed regarding care plan updates
LPN BBLicensed Practical NurseInterviewed regarding medication administration for resident #21
LPN WN IILicensed Practical Nurse/Wound Nurse IIInterviewed regarding medication administration and wound care for resident #21
Dietary ManagerInterviewed regarding ice machine maintenance and cleaning

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Jan 10, 2019

Visit Reason
An unannounced survey was conducted from January 9, 2019 through January 10, 2019 to investigate a complaint identified as GA00192958.

Complaint Details
Complaint GA00192958 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Inspection Report

Deficiencies: 0 Date: Oct 9, 2018

Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Woodlands Health Care, indicating a regulatory inspection was conducted.

Findings
No specific deficiencies or findings are detailed in the provided document.

Inspection Report

Abbreviated Survey
Deficiencies: 0 Date: Sep 4, 2018

Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00190008.

Complaint Details
Complaint #GA00190008 was investigated and found to be unsubstantiated.
Findings
The complaint investigated during the survey was found to be unsubstantiated.

Inspection Report

Abbreviated Survey
Census: 114 Deficiencies: 0 Date: Apr 18, 2018

Visit Reason
An abbreviated survey was conducted on April 17th and 18th, 2018 to investigate complaint GA00187437.

Complaint Details
Investigation of complaint GA00187437 determined the facility was in compliance.
Findings
The facility was found to be in compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.

Inspection Report

Re-Inspection
Deficiencies: 0 Date: Mar 16, 2018

Visit Reason
A Revisit Survey was conducted at Woodlands Health Care on 3/16/18 to verify correction of deficiencies cited during the Complaint survey of 1/19/18.

Complaint Details
The revisit survey was conducted following a complaint survey on 1/19/18; all prior deficiencies were corrected.
Findings
All deficiencies cited as a result of the Complaint survey of 1/19/18 were found to be corrected during this revisit survey.

Inspection Report

Re-Inspection
Deficiencies: 0 Date: Mar 16, 2018

Visit Reason
A Revisit Survey was conducted at Woodlands Health Care on 3/16/18 to verify correction of deficiencies cited during the Standard survey of 2/2/18.

Findings
All deficiencies cited as a result of the Standard survey of 2/2/18 were found to be corrected during the revisit survey.

Inspection Report

Follow-Up
Deficiencies: 0 Date: Mar 12, 2018

Visit Reason
A Follow-Up Survey was conducted to verify that previously cited survey tags had been corrected.

Findings
The surveyor noted that all previously cited survey tags had been corrected.

Inspection Report

Routine
Census: 115 Deficiencies: 4 Date: Feb 2, 2018

Visit Reason
A standard survey was conducted to assess compliance with Medicare/Medicaid regulations for Magnolia Manor of Midway.

Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to accurately reflect resident falls on assessments, failure to revise care plans after falls, inadequate determination of root causes of falls, and improper food storage and labeling in resident pantries.

Deficiencies (4)
Failure to accurately reflect fall status on Minimum Data Sets (MDS) for Resident #29, resulting in actual harm from a fall with injury.
Failure to revise care plan after each fall for Resident #29 to include new or appropriate interventions to prevent further falls.
Failure to determine root cause of falls and implement appropriate interventions for Resident #29, despite multiple documented falls.
Failure to discard expired or unlabeled food items and maintain clean and sanitary conditions in three resident pantry refrigerators.
Report Facts
Resident census: 115 Sample size: 27 Number of falls documented for Resident #29: 8 Expired food items: 9

Employees mentioned
NameTitleContext
Licensed Practical Nurse NNRestorative Nurse and MDS CoordinatorResponsible for coding falls on residents' MDS; confirmed failure to accurately capture falls for Resident #29
Licensed Practical Nurse DDLicensed Practical Nurse/MDS CoordinatorResponsible for documenting new interventions on residents' care plans
Certified Nursing Assistant OOCNAProvided care for Resident #29 and described fall risks and toileting assistance
Certified Nursing Assistant RRCNAProvided toileting assistance to Resident #29
Certified Nursing Assistant PPCNAProvided care for Resident #29 and described resident's behavior
Hospice CNA QQHospice CNAProvided care for Resident #29
Licensed Practical Nurse HHLicensed Practical NurseProvided nursing care and described fall prevention efforts for Resident #29
Physical Therapist Assistant SSPhysical Therapist AssistantScreened Resident #29 and provided education on safety and call light use
Director of NursingDirector of NursingOversaw fall prevention meetings and interventions
Registered Nurse EERegistered NurseDescribed responsibilities for maintaining pantry refrigerators
Facility AdministratorFacility AdministratorConfirmed night shift responsibility for pantry refrigerator maintenance and food labeling

Inspection Report

Routine
Deficiencies: 1 Date: Feb 2, 2018

Visit Reason
The inspection was conducted to assess compliance with nursing care requirements, specifically focusing on the facility's management of resident falls and the adequacy of care plans and interventions.

Findings
The facility failed to determine the root cause of each fall and did not revise the care plan with appropriate interventions to prevent further falls for one resident (R#29) who sustained multiple falls, including one with injury requiring staples. Staff failed to capture all falls on the Quarterly MDS and did not evaluate the effectiveness of interventions such as educating the resident to use the call light.

Deficiencies (1)
Failure to determine root cause of falls and revise care plan with new or appropriate interventions to prevent further falls for resident #29.
Report Facts
Sample size: 27 Number of falls documented for resident #29: 8 Number of falls with injury: 1 Number of falls during 3:00 p.m. to 11:00 p.m. shift: 6

Employees mentioned
NameTitleContext
Licensed Practical Nurse NNRestorative Nurse and MDS CoordinatorResponsible for coding falls on MDS and acknowledged failure to accurately capture falls and revise care plans
Licensed Practical Nurse HHLicensed Practical NurseProvided information about resident's fall risk and communication of fall interventions to staff
Certified Nursing Assistant OOCertified Nursing AssistantProvided care and described resident's fall risk and use of call light
Certified Nursing Assistant RRCertified Nursing AssistantProvided care and described resident's incontinence and toileting assistance
Certified Nursing Assistant PPCertified Nursing AssistantProvided care and described resident's behavior and fall awareness
Hospice CNA QQHospice Certified Nursing AssistantProvided care and assisted resident with toileting
Physical Therapist Assistant SSPhysical Therapist AssistantProvided information on therapy screening and coordination with Hospice
Director of NursingDirector of NursingProvided information on facility fall management meetings and interventions
Licensed Practical Nurse DDLicensed Practical Nurse/MDS CoordinatorDiscussed documentation of fall interventions in morning meetings

Inspection Report

Life Safety
Census: 114 Capacity: 169 Deficiencies: 9 Date: Jan 30, 2018

Visit Reason
The inspection was conducted as a Life Safety Code Survey to assess compliance with fire safety and emergency preparedness regulations at Woodlands Nursing Center.

Findings
The facility was found not in substantial compliance with emergency preparedness testing requirements and multiple Life Safety Code deficiencies including improper door locking hardware, lack of emergency lighting at exits, inadequate door closures on storage rooms, outdated sprinkler system inspection, unsealed smoke barriers, unsafe power strip placement, missing smoking area safety containers, and missing 'No Smoking - Oxygen in Use' signs in patient rooms.

Deficiencies (9)
Facility failed to conduct two required emergency preparedness exercises within one year.
Failed to maintain proper fire code compliant access controlled egress door hardware on multiple exits.
Failed to provide required emergency lighting at all required exits.
Failed to maintain required door closures on doors to storage spaces over 50 square feet.
Failed to provide required annual sprinkler system inspection and maintain sprinkler piping on smoking patio and rear exterior covered area.
Failed to maintain smoke barrier sealing between top of smoke barrier and roof deck to maintain 1/2 hour fire resistance rating.
Failed to maintain power strips off the floor in staff office areas.
Failed to maintain required metal container with self-closing cover for emptying ashtrays in smoking patio area.
Failed to maintain 'No Smoking - Oxygen in Use' signs at patient rooms where oxygen concentrators were in use.
Report Facts
Census: 114 Total Capacity: 169 Deficiencies cited: 9 Last sprinkler inspection date: 2016 Number of doors with non-compliant locking hardware: 3

Employees mentioned
NameTitleContext
Staff MConfirmed findings during facility tour and interviews

Inspection Report

Abbreviated Survey
Deficiencies: 0 Date: Oct 19, 2017

Visit Reason
An abbreviated survey was conducted to investigate complaint GA00176561 at Woodlands Health Care.

Complaint Details
Investigation of complaint GA00176561; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.

Inspection Report

Abbreviated Survey
Deficiencies: 0 Date: Sep 21, 2017

Visit Reason
An abbreviated survey was conducted to investigate complaint GA00179705 at Woodlands Health and Rehabilitation.

Complaint Details
Complaint GA00179705 was investigated during this abbreviated survey.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Sep 14, 2017

Visit Reason
The inspection was conducted to investigate complaint GA00179515.

Complaint Details
Complaint GA00179515 was investigated and found to have no health deficiencies.
Findings
No health deficiencies were cited during the complaint survey.

Inspection Report

Follow-Up
Deficiencies: 0 Date: Jun 26, 2017

Visit Reason
A follow-up survey was conducted on 6/26/17 to verify correction of deficiencies identified in the survey of 5/25/17.

Findings
The deficiencies identified in the previous survey of 5/25/17 had been corrected as of the follow-up survey on 6/26/17.

Inspection Report

Complaint Investigation
Deficiencies: 4 Date: May 25, 2017

Visit Reason
An abbreviated survey was conducted to investigate complaints GA00175113 and GA00175179 regarding the facility's compliance with Medicare/Medicaid regulations.

Complaint Details
The investigation was initiated based on complaints GA00175113 and GA00175179. It was substantiated that the facility failed to notify the physician and family of significant weight loss, failed to individualize care plans, and failed to maintain nutritional status for resident #1.
Findings
The facility was found not in substantial compliance due to failure to notify the physician or resident's representative of significant weight loss for one resident, failure to individualize the care plan and provide effective restorative nursing for dining, and failure to maintain nutritional status with adequate interventions to prevent weight loss.

Deficiencies (4)
Failure to notify the physician or resident's representative of significant trending weight loss for one resident.
Failure to individualize the care plan for significant weight loss and restorative dining for one resident.
Failure to provide appropriate treatment and services to maintain or improve activities of daily living, specifically an ineffective restorative nursing program for dining.
Failure to maintain nutritional status and provide adequate interventions to prevent weight loss for one resident.
Report Facts
Weight loss: 47 Weight loss percentage: 12.5 Weight loss threshold: 5 Weight loss threshold: 7.5 Weight loss threshold: 10 Albumin level: 2.1 Oral intake: 50

Employees mentioned
NameTitleContext
MMLicensed Practical Nurse (LPN)Interviewed and revealed that the physician or family member had not been notified of resident #1's significant weight loss.
EERestorative Certified Nursing Aide (RNA)Interviewed and revealed resident #1 was on restorative nursing program for dining but this was not addressed in the care plan.
PhysicianInterviewed and stated he was unaware of resident #1's additional weight loss and would have intervened if informed.
Minimum Data Set (MDS) CoordinatorInterviewed and admitted limiting care plan interventions for weight loss was an oversight.
Rehabilitation ManagerInterviewed and stated speech therapy evaluation was based on nursing information; therapy had not received communication about resident #1's weight loss.
Speech TherapistInterviewed and described feeding requirements for resident #1.
Dietary ManagerInterviewed and described weight review process and communication with Director of Nursing.
Registered Dietitian (RD)Interviewed and reviewed resident #1's weights and noted no recommendations were made despite weight loss.
Maintenance DirectorDemonstrated facility scales were operational.

Inspection Report

Follow-Up
Deficiencies: 0 Date: Apr 7, 2017

Visit Reason
An abbreviated follow-up survey was conducted to determine if the facility had achieved substantial compliance with Medicare and Medicaid regulations as alleged on the Plan of Correction.

Findings
The facility was found to be in substantial compliance with Medicare and Medicaid regulations at 42 CFR 483 Subpart B - Requirements for Long Term Care Facilities.

Inspection Report

Follow-Up
Deficiencies: 0 Date: Apr 3, 2017

Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey deficiencies had been corrected.

Findings
The surveyor noted that all previously cited survey tags have been corrected.

Inspection Report

Life Safety
Census: 113 Capacity: 169 Deficiencies: 6 Date: Jan 31, 2017

Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.

Findings
The facility was found not in substantial compliance with several fire safety requirements including emergency lighting testing documentation, kitchen hood suppression system inspection records, fire alarm system testing and maintenance documentation, sprinkler system installation and maintenance, and integrity of smoke barrier walls.

Deficiencies (6)
Failed to maintain records documenting monthly and annual testing of emergency lights.
Failed to provide records documenting inspections, testing, and maintenance of the kitchen hood suppression system.
Failed to provide documentation for inspection, testing, and maintenance of the fire alarm system including sensitivity testing for smoke detectors.
Facility failed to protect resident room closets with approved, supervised automatic sprinkler system.
Failed to provide records documenting inspections, testing, and maintenance of the automatic sprinkler system including 5-year internal inspection and backflow preventer tests; sprinkler riser was yellow-tagged indicating deficiencies.
Failed to maintain the integrity of smoke barrier walls with unsealed penetrations allowing wires to pass through.
Report Facts
Census: 113 Total Capacity: 169 Date of last documented monthly emergency light test: 201610 Date of last semi-annual kitchen hood suppression system inspection: May 11, 2016 Date of inspection: Jan 31, 2017

Employees mentioned
NameTitleContext
Staff Member MConfirmed findings related to kitchen hood suppression system, fire alarm system, sprinkler system, and smoke barrier wall deficiencies

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