Inspection Reports for
Magnolia Wellness Center

The investigation was complaint-driven, focusing on behavioral health care deficiencies and pharmaceutical service issues. The complaint included concerns about resident safety, medication management, and policy compliance. Substantiation status is not explicitly stated.

The facility failed to provide adequate behavioral health care for residents exhibiting problematic behaviors including aggression and policy violations. Additionally, the facility failed to maintain accurate and thorough records of controlled substances, with incomplete documentation of narcotic inventory counts and signatures.

The investigation was complaint-driven due to a resident fall caused by broken Hoyer lift straps during transfer. The fall resulted in a minor head laceration. The evidence suggested incorrect pad use but neglect was not substantiated.

The facility failed to ensure adequate assistance and proper equipment use during resident transfer, resulting in a resident falling when the sling straps broke, causing a head laceration. The investigation found that incorrect lift pads were used, but neglect was not substantiated.

The complaint investigation found that a staff member threatened Resident #6 using profanity and was suspended and later terminated. Residents #1 and #2 were involved in a physical altercation where Resident #2 pushed Resident #1 to the floor. Resident #2 was under the influence of alcohol and was sent to the hospital for evaluation. The police were notified and issued a citation for peace disturbance. The facility conducted interviews, provided education, and implemented behavior monitoring and referrals for alcohol abuse treatment.

The facility failed to protect residents from abuse, including verbal threats by a staff member and a physical altercation between two residents, one involving alcohol use. The facility took immediate corrective actions including staff suspension and termination, resident separation, medical evaluations, and staff education on abuse prevention and de-escalation.

The complaint was substantiated. The dietary aide argued with the resident, used disrespectful language, and failed to provide requested condiments. The aide was terminated and staff were educated on proper customer service and de-escalation techniques.

The facility failed to ensure residents were treated with respect and dignity when a dietary aide argued with a resident and did not provide requested condiments. The dietary aide was terminated and staff were educated on de-escalation and customer service.

Two deficiencies were identified related to providing appropriate treatment and care according to orders and resident preferences, and ensuring appropriate care to maintain or improve range of motion and mobility. Both deficiencies were noted with minimal harm or potential for actual harm and affected a few or some residents.

The facility failed to consistently notify physicians of residents' high blood glucose levels, ensure proper wound care and protective equipment use, maintain an active restorative nursing program, ensure medication error rates were below 5%, and implement enhanced barrier precautions for infection control.

The complaint investigation involved incidents on 2/25/25 where Resident #6 was agitated and kicked Resident #8, and later was choked by Resident #5 causing visible bruising and a sore throat. The facility's investigation included interviews, assessments, and review of care plans. Staff failed to intervene adequately before escalation. Resident #6 was placed on 1:1 supervision after the incidents and later sent for psychiatric evaluation. The facility was cited for failure to prevent abuse and to provide adequate behavioral health care services.

The facility failed to ensure residents were free from abuse, specifically physical altercations between residents, and failed to provide necessary behavioral health care services to manage residents' agitation and aggressive behaviors. Staff interventions prior to escalation were inadequate, leading to physical harm including choking and bruising.

The complaint involved a physical altercation on 6/26/24 where Resident #2 choked Resident #1. The incident was substantiated with witness statements from nursing staff and observations. Resident #2 was sent to the hospital and monitored closely upon return. Resident #1 declined initial room relocation but later agreed. The facility implemented interventions including monitoring and consideration of keypad locks for resident safety.

The facility failed to ensure a resident's right to be free from abuse when Resident #2 placed hands around Resident #1's neck during a physical altercation. Staff intervened immediately, separated the residents, and provided assessments and services. Resident #2 was sent to the hospital and monitored upon return. Resident #1 was offered room relocation and keypad lock options for safety.

The complaint investigation substantiated immediate jeopardy beginning on 2024-04-05 due to failure to monitor and treat a resident in respiratory distress. The immediate jeopardy was removed on 2024-05-01 after corrective actions were verified.

The facility failed to provide acceptable nursing services by not continuously monitoring and intervening for a resident in respiratory distress, resulting in delayed oxygen treatment and the resident's subsequent death. The oxygen concentrator was broken, the emergency oxygen tank was empty, and the resident was found unattended with critically low oxygen saturation levels.

The complaint investigation was initiated due to a mechanical lift failure incident involving Resident 73, which resulted in serious injury and death. The investigation substantiated immediate jeopardy due to failure to have two staff present and equipment malfunction.

The facility failed to ensure two staff were present during mechanical lift transfers, resulting in a lift collapse and resident injury leading to death. Additional findings included untimely medication administration, food safety violations, unsafe resident equipment, and inaccessible EMS access.

The facility had multiple deficiencies including failure to prevent negative balances in resident trust accounts, incomplete resident assessments, missing PASARR screening, lack of care conferences, unqualified activities director, mechanical lift failure causing resident injury and death, unsafe bed rail design, late medication administration, improper pureed food consistency, food safety violations, inadequate bed and wheelchair maintenance, inaccessible EMS doorbell, and insufficient lift equipment training for staff.

The facility failed to employ a licensed Nursing Home Administrator responsible for overall operation and resident care oversight. The Administrator position was vacant since 2/26/23, with a sister facility's Administrator providing limited support but not acting as the official Administrator.

The facility had multiple deficiencies including failure to communicate visitation policy changes timely, incomplete code status documentation, inadequate environmental maintenance, insufficient investigation of abuse allegations, incomplete care plans, medication administration errors, failure to provide adequate showering and activities, lack of licensed nursing coverage, incomplete infection control program implementation, and failure to provide COVID-19 vaccine boosters to residents.

The facility was found deficient in multiple areas including resident dignity and respect, financial management of resident funds, notification and refund of discharged residents' funds, posting of survey results, advance directive documentation, maintenance of a safe and homelike environment, accuracy of resident assessments, quality of care including medication orders and wound care, personal care assistance, activity programming, pressure ulcer care, restorative therapy, accident prevention, medication storage and labeling, dialysis care, and infection control.