Inspection Reports for
Magnolia Manor of Midway
652 NORTH COASTAL HIGHWAY 17, MIDWAY, GA, 31320
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
84% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
67% occupied
Based on a May 2019 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Dec 5, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of resident-to-resident abuse, failure to report suspected abuse timely, failure to develop or revise comprehensive care plans following abuse incidents, and concerns regarding vaccination consent and documentation.
Complaint Details
The complaint investigation substantiated verbal and physical resident-to-resident abuse involving residents R1, R8, and R23. The facility failed to report abuse timely to the State Agency and failed to update care plans accordingly. The investigation included witness statements and interviews confirming abuse incidents and inadequate facility responses.
Findings
The facility failed to prevent and properly report resident-to-resident abuse involving three residents. Care plans were not updated to address abuse victimization or aggressive behaviors. The facility also failed to assess and obtain consent for bed rail use and failed to provide residents or their representatives with risks and benefits information prior to administering pneumococcal, flu, and COVID-19 vaccines.
Deficiencies (8)
F0600: The facility failed to protect residents from verbal and physical abuse by other residents and failed to investigate and intervene appropriately.
F0609: The facility failed to timely report suspected abuse and failed to notify the State Agency within required timeframes.
F0656: The facility failed to develop comprehensive care plans addressing abuse victimization for residents who experienced abuse.
F0657: The facility failed to revise a resident's care plan to include interventions to prevent further abuse after incidents occurred.
F0688: The facility failed to provide appropriate assistive devices or treatment to prevent further decline in range of motion for a resident with wrist contracture.
F0700: The facility failed to assess entrapment risk and obtain consent for bed rail use for a resident using bed rails for mobility assistance.
F0883: The facility failed to ensure residents or their representatives were provided risks and benefits information and offered pneumococcal and flu vaccines according to CDC guidelines.
F0887: The facility failed to ensure residents or their representatives were provided risks and benefits information and offered COVID-19 vaccines/boosters according to CDC guidelines.
Report Facts
Residents sampled: 26
Residents reviewed for positioning/mobility: 7
Residents reviewed for vaccination: 5
BIMS scores: 7
BIMS scores: 3
BIMS scores: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN5 | Licensed Practical Nurse | Named in reporting and investigation of resident abuse incidents |
| LPN1 | Licensed Practical Nurse | Witnessed resident abuse incident and reported it |
| CNA1 | Certified Nursing Assistant | Witnessed and reported resident verbal abuse incident |
| DON | Director of Nursing | Interviewed regarding abuse incidents, reporting, and care plan deficiencies |
| LPNUM | Licensed Practical Nurse Unit Manager | Interviewed regarding abuse incident reporting and supervision |
| DOR | Director of Rehab | Interviewed regarding occupational therapy and assistive device use for resident |
| OTA | Occupational Therapy Assistant | Interviewed regarding therapy services and orthotic management |
| IP | Infection Preventionist | Interviewed regarding vaccination consent and education deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 9, 2025
Visit Reason
The inspection was conducted due to complaints regarding medication errors and failure to protect residents from allergic reactions and omission of necessary medications.
Complaint Details
The investigation was complaint-driven, focusing on medication errors involving allergic reactions and omission of necessary medications. Harm was substantiated as actual harm occurred to residents.
Findings
The facility failed to protect one resident from an allergic reaction after administering a medication to which they were allergic, and failed to order an anticonvulsant medication for another resident, resulting in rehospitalization due to seizure activity. Deficiencies were found in medication administration, order entry, allergy documentation, and communication between staff and pharmacy.
Deficiencies (2)
F 0658: The facility failed to protect a resident with known allergies by administering Bactrim DS, resulting in an allergic reaction with flushing, redness, and rash. Safety alerts were bypassed without proper notification to the provider.
F 0760: The facility failed to order an anticonvulsant medication for a resident, leading to seizure activity and rehospitalization. Medication orders were not entered into the EMR upon readmission from the hospital.
Report Facts
Residents sampled: 33
Residents sampled: 17
Doses administered: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse Unit Manager | Named in medication allergy error finding for entering Bactrim DS order and bypassing safety alert |
| LPN FF | Licensed Practical Nurse | Entered telephone order for Bactrim DS and administered first dose from emergency kit |
| LPN CC | Licensed Practical Nurse | Discovered medication error and notified Director of Nursing |
| Director of Nursing | Director of Nursing | Provided education on medication errors and managed response to allergic reaction |
| Staff Pharmacist DD | Staff Pharmacist | Described pharmacy order processing and allergy alert system |
| Director of Pharmacy Services | Director of Pharmacy Services | Confirmed allergy data transmission issues and missing allergy alerts |
| Staff Pharmacist HH | Staff Pharmacist | Discussed medication order integration and processing for anticonvulsant investigation |
| Pharmacy Consultant | Facility Pharmacy Consultant | Reviewed medical records and medication orders for concerns |
| Assistant Director of Nursing | Assistant Director of Nursing | Described order receipt and review process upon resident hospital readmission |
| Administrator | Facility Administrator | Discussed nurse education and communication tools for medication orders and alerts |
Inspection Report
Routine
Deficiencies: 7
Date: Jun 14, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, restorative nursing, infection control, environmental safety, and food safety at Magnolia Manor of Midway.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy during care, inadequate accommodation of resident needs, failure to maintain a clean and odor-free environment, incomplete care plans, lack of restorative nursing services, improper food labeling and hygiene practices, and failure to use appropriate personal protective equipment during high-contact care.
Deficiencies (7)
F 0550: The facility failed to ensure privacy during Activity of Daily Living care for one resident and failed to provide a privacy bag for a resident's urinary catheter drainage bag.
F 0558: The facility failed to reasonably accommodate the needs and preferences of residents by not providing a properly fitted chair and failing to assess residents for placement on the secured unit.
F 0584: The facility failed to maintain a clean, sanitary environment free of odor, replace missing floor tiles, and ensure resident equipment was free from rust on two of three halls.
F 0656: The facility failed to develop and implement a complete care plan for two residents, including a plan to monitor and prevent abuse and a plan for restorative services.
F 0688: The facility failed to provide restorative nursing services to three residents, including failure to provide a properly fitted chair, footrest, and range of motion exercises.
F 0812: The facility failed to properly label opened food items, discard expired foods, clean the ice machine, and ensure kitchen staff wore beard guards.
F 0880: The facility failed to ensure staff used appropriate personal protective equipment for one resident reviewed for Enhanced Barrier Precautions.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 9
Residents affected: 28
Residents affected: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA BB | Certified Nursing Assistant | Named in privacy and PPE use findings |
| CNA AA | Certified Nursing Assistant | Named in privacy findings |
| Assistant Director of Nursing (ADON) | Interviewed regarding privacy and PPE use | |
| Licensed Practical Nurse (LPN FF) | Licensed Practical Nurse | Interviewed regarding catheter dignity bag |
| Unit Manager | Interviewed regarding catheter dignity bag | |
| Director of Nursing (DON) | Interviewed regarding resident accommodation and restorative care | |
| Dietary CC | Acting Dietary Manager | Interviewed regarding food safety and hygiene |
| Infection Control Preventionist (IPC) | Interviewed regarding PPE use and infection control | |
| Restorative Care Nurse/RN | Registered Nurse | Interviewed regarding restorative care assessments |
| Occupational Therapist (OT) | Interviewed regarding footrest and wheelchair positioning | |
| Unit Nurse Supervisor Licensed Practical Nurse (LPN) MM | Licensed Practical Nurse | Interviewed regarding footrest for resident |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 6, 2023
Visit Reason
Annual survey inspection of Magnolia Manor of Midway nursing home to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 12, 2022
Visit Reason
Annual inspection survey of Magnolia Manor of Midway nursing home to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
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
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed 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
| Name | Title | Context |
|---|---|---|
| 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
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding care plan oversight and infection control documentation | |
| Director of Nursing | DON | Interviewed about infection prevention and care plan responsibilities |
| MDS Coordinator | Responsible 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
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed 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
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed 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) Coordinator | Responsible for some care plans; interviewed regarding care plan updates | |
| LPN BB | Licensed Practical Nurse | Interviewed regarding medication administration for resident #21 |
| LPN WN II | Licensed Practical Nurse/Wound Nurse II | Interviewed regarding medication administration and wound care for resident #21 |
| Dietary Manager | Interviewed 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
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse NN | Restorative Nurse and MDS Coordinator | Responsible for coding falls on residents' MDS; confirmed failure to accurately capture falls for Resident #29 |
| Licensed Practical Nurse DD | Licensed Practical Nurse/MDS Coordinator | Responsible for documenting new interventions on residents' care plans |
| Certified Nursing Assistant OO | CNA | Provided care for Resident #29 and described fall risks and toileting assistance |
| Certified Nursing Assistant RR | CNA | Provided toileting assistance to Resident #29 |
| Certified Nursing Assistant PP | CNA | Provided care for Resident #29 and described resident's behavior |
| Hospice CNA QQ | Hospice CNA | Provided care for Resident #29 |
| Licensed Practical Nurse HH | Licensed Practical Nurse | Provided nursing care and described fall prevention efforts for Resident #29 |
| Physical Therapist Assistant SS | Physical Therapist Assistant | Screened Resident #29 and provided education on safety and call light use |
| Director of Nursing | Director of Nursing | Oversaw fall prevention meetings and interventions |
| Registered Nurse EE | Registered Nurse | Described responsibilities for maintaining pantry refrigerators |
| Facility Administrator | Facility Administrator | Confirmed 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
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse NN | Restorative Nurse and MDS Coordinator | Responsible for coding falls on MDS and acknowledged failure to accurately capture falls and revise care plans |
| Licensed Practical Nurse HH | Licensed Practical Nurse | Provided information about resident's fall risk and communication of fall interventions to staff |
| Certified Nursing Assistant OO | Certified Nursing Assistant | Provided care and described resident's fall risk and use of call light |
| Certified Nursing Assistant RR | Certified Nursing Assistant | Provided care and described resident's incontinence and toileting assistance |
| Certified Nursing Assistant PP | Certified Nursing Assistant | Provided care and described resident's behavior and fall awareness |
| Hospice CNA QQ | Hospice Certified Nursing Assistant | Provided care and assisted resident with toileting |
| Physical Therapist Assistant SS | Physical Therapist Assistant | Provided information on therapy screening and coordination with Hospice |
| Director of Nursing | Director of Nursing | Provided information on facility fall management meetings and interventions |
| Licensed Practical Nurse DD | Licensed Practical Nurse/MDS Coordinator | Discussed 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
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed 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
| Name | Title | Context |
|---|---|---|
| MM | Licensed Practical Nurse (LPN) | Interviewed and revealed that the physician or family member had not been notified of resident #1's significant weight loss. |
| EE | Restorative 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. |
| Physician | Interviewed and stated he was unaware of resident #1's additional weight loss and would have intervened if informed. | |
| Minimum Data Set (MDS) Coordinator | Interviewed and admitted limiting care plan interventions for weight loss was an oversight. | |
| Rehabilitation Manager | Interviewed and stated speech therapy evaluation was based on nursing information; therapy had not received communication about resident #1's weight loss. | |
| Speech Therapist | Interviewed and described feeding requirements for resident #1. | |
| Dietary Manager | Interviewed 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 Director | Demonstrated 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
| Name | Title | Context |
|---|---|---|
| Staff Member M | Confirmed findings related to kitchen hood suppression system, fire alarm system, sprinkler system, and smoke barrier wall deficiencies |
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