Inspection Reports for
Pruitthealth – Magnolia Manor
3003 VETERANS PARKWAY S, MOULTRIE, GA, 31788
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
14.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
192% worse than Georgia average
Georgia average: 4.9 deficiencies/year
Deficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
87% occupied
Based on a December 2024 inspection.
Occupancy rate over time
Inspection Report
Deficiencies: 0
Date: Dec 19, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for PruittHealth - Magnolia Manor, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 87
Deficiencies: 0
Date: Dec 19, 2024
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited in the November 1, 2024, recertification survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Deficiencies: 0
Date: Dec 17, 2024
Visit Reason
A Life Safety Code Revisit was conducted to verify correction of previously cited Life Safety Code deficiencies.
Findings
All previously cited Life Safety Code deficiencies had been corrected.
Inspection Report
Routine
Deficiencies: 16
Date: Nov 1, 2024
Visit Reason
Routine inspection of Pruitthealth - Magnolia Manor to assess compliance with healthcare facility regulations including resident care, safety, and infection control.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity and rights, improper medication storage, inadequate care plans, environmental hazards, failure to provide necessary mental health and vision services, poor infection control practices, and unsafe food handling procedures.
Deficiencies (16)
F0550: Facility failed to ensure facial hair was removed upon request for one resident, violating resident dignity and rights.
F0554: Unauthorized and expired medications were stored at bedside for one resident, risking unauthorized access.
F0578: Facility failed to provide written information about advance directives to four residents, denying informed healthcare decisions.
F0584: Facility failed to maintain a safe, clean, and homelike environment including stained pillows, trip hazards, cracked toilets, and unsanitary water fountains.
F0585: Facility failed to inform residents of grievance official and grievance process, limiting residents' ability to voice concerns.
F0645: Facility failed to submit PASARR Level II applications for five residents with mental health diagnoses, risking lack of specialized care.
F0656: Facility failed to develop and implement comprehensive care plans for five residents, including ADL, psychiatric, and vision care.
F0677: Facility failed to provide adequate ADL care for six residents, including missed showers, incontinence care, and nail care.
F0685: Facility failed to assist two residents in gaining access to vision services, resulting in uncorrected vision problems.
F0688: Facility failed to follow occupational therapy restorative nursing program for splint use for one resident, risking contracture progression.
F0689: Facility failed to ensure environment free from accident hazards including unsecured oxygen tank, aerosol cans in resident room, and inadequate fall prevention supervision.
F0692: Facility failed to provide evidence of nutrition assessments by registered dietitian for three residents with weight loss.
F0695: Facility failed to ensure oxygen therapy equipment was properly maintained and clean for two residents, increasing infection risk.
F0740: Facility failed to provide necessary behavioral health care and services for three residents with mental health diagnoses.
F0812: Facility failed to procure, store, prepare, and serve food in accordance with professional standards including expired food, unlabeled items, and improper feeding techniques.
F0880: Facility failed to implement infection prevention and control program including improper medication administration practices, contaminated equipment, and poor hand hygiene.
Report Facts
Residents sampled: 28
Residents affected: 89
Weight loss: 7
Weight loss: 41
Weight loss: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN MM | Licensed Practical Nurse | Named in infection control deficiency related to fingerstick blood sugar procedure |
| CNA AA | Certified Nursing Assistant | Named in feeding and hand hygiene deficiencies |
| Director of Health Services | Named in multiple interviews regarding expectations and deficiencies | |
| Social Services Director | Named in mental health service deficiencies | |
| Dietary Manager | Named in food storage and nutrition assessment deficiencies | |
| Registered Dietitian WW | Registered Dietitian | Named in nutrition assessment deficiencies |
Inspection Report
Routine
Deficiencies: 6
Date: Nov 1, 2024
Visit Reason
The inspection was a State Licensure survey conducted to determine compliance with State Long Term Care Requirements.
Findings
The facility was cited for multiple deficiencies including failure to maintain effective infection control practices during medication administration, failure to ensure unauthorized and expired medications were not stored at bedside, failure to develop and implement comprehensive care plans for several residents, failure to provide Activities of Daily Living (ADL) care according to residents' needs, failure to apply prescribed orthotic devices, environmental safety hazards, and failure to maintain sanitary food storage and delivery practices.
Deficiencies (6)
Failure to maintain effective infection control practices during medication administration and resident care.
Unauthorized and expired medications stored at bedside of resident R16.
Failure to develop and implement comprehensive care plans for five residents and failure to provide ADL care including bathing, incontinence care, nail care, and orthotic application.
Failure to maintain a safe, clean, and homelike environment including stained pillows, trip hazards from electrical sockets, cracked toilet, unsanitary water fountains, unsecured oxygen tank, aerosol cans in resident rooms, and inadequate supervision for high fall risk residents.
Failure to discard expired food items, label and date food items properly, and failure to ensure sanitary food delivery practices in dining room.
Failure to use utensils and proper hand hygiene during feeding assistance.
Report Facts
Residents sampled for care plan deficiencies: 28
Residents assessed for falls: 10
Residents receiving oral diet: 89
Residents in dining room during feeding observation: 8
Expired food items found: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN MM | Licensed Practical Nurse | Named in infection control deficiencies related to medication administration. |
| CNA AA | Certified Nursing Assistant | Named in infection control and feeding assistance deficiencies. |
| RN CC | Registered Nurse, Unit Manager | Named in infection control and care plan deficiencies. |
| LPN RR | Licensed Practical Nurse | Named in medication storage and oxygen safety deficiencies. |
| CNA QQ | Certified Nursing Assistant | Named in orthotic application and incontinence care deficiencies. |
| DHS | Director of Health Services | Named in multiple findings including infection control, care plans, environment, and safety. |
| DM | Dietary Manager | Named in food storage and labeling deficiencies. |
| RN EE | Registered Nurse | Named in nail care and fall prevention deficiencies. |
| CNA NN | Certified Nursing Assistant | Named in fall prevention and orthotic application deficiencies. |
Inspection Report
Re-Inspection
Census: 91
Deficiencies: 15
Date: Nov 1, 2024
Visit Reason
A recertification survey was conducted from October 29, 2024 through November 1, 2024, including investigation of three complaint intake numbers. The survey was to assess compliance with Medicare/Medicaid regulations and investigate complaints.
Complaint Details
Complaint Intake Numbers GA00250141 and GA00251564 were substantiated with deficiencies. Intake number GA00250772 was unsubstantiated.
Findings
The facility was found not in substantial compliance with multiple deficiencies including failure to provide care respecting resident dignity, failure to remove unauthorized and expired medications, failure to provide advance directive information, unsafe and unsanitary environment issues, failure to ensure grievance process knowledge, failure to submit PASARR Level II applications for residents with mental health diagnoses, failure to implement care plans for ADL, psychiatric, and vision services, failure to provide adequate incontinence and bathing care, failure to follow restorative nursing recommendations, unsafe oxygen equipment storage, failure to obtain mental health services, failure to maintain infection control during medication administration, and failure to properly label, date, and discard food items.
Deficiencies (15)
Failed to provide care maintaining resident dignity by not removing facial hair as requested.
Unauthorized and expired medications stored at bedside.
Failed to provide residents written information about rights to accept or refuse medical or surgical treatment.
Facility environment unsafe and unsanitary including stained pillows, trip hazards, cracked toilet, and unclean water fountains.
Failed to ensure residents were informed of grievance official and grievance process.
Failed to submit PASARR Level II applications for residents with mental health diagnoses.
Failed to implement care plans for ADL, psychiatric, vision, and incontinence care.
Failed to obtain vision services for residents with impaired vision.
Failed to follow occupational therapy restorative nursing program recommendation for orthotic splint use.
Failed to ensure oxygen tank was properly secured and aerosol cans removed from resident rooms; failed to provide adequate supervision for high fall risk residents.
Failed to provide evidence of nutrition assessments by registered dietitian for residents with weight loss.
Failed to ensure oxygen tubing and nebulizer masks were covered and not resting on floor.
Failed to obtain mental health services for residents with psychiatric diagnoses.
Failed to discard expired food items, label and date food items properly, and maintain sanitary food delivery practices.
Failed to maintain infection control during medication administration including improper glove use, hand hygiene, and contaminated equipment.
Report Facts
Residents present: 91
Weight loss: 7
Weight loss: 41
Weight loss: 51
Blood sugar: 231
Oxygen liters: 2
Oxygen liters: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN MM | Licensed Practical Nurse | Performed fingerstick blood sugar and insulin administration with poor infection control |
| CNA AA | Certified Nursing Assistant | Fed resident with fingers, did not wash hands before assisting with eating |
| LPN RR | Licensed Practical Nurse | Aware of oxygen tank safety risk, removed unsecured oxygen tank |
| DHS | Director of Health Services | Provided multiple interviews regarding expectations for care, safety, and compliance |
| SSD | Social Services Director | Discussed psychiatric referrals and resident counseling refusals |
| RN CC | Unit Manager/Registered Nurse | Discussed missed showers and hand hygiene expectations |
| CNA QQ | Certified Nursing Assistant | Confirmed facial hair not removed, splint not applied, and incontinent care delays |
| RN EE | Registered Nurse | Discussed fall protocol and infection control |
| RD WW | Registered Dietitian | Confirmed missed nutrition assessments |
| DM | Dietary Manager | Confirmed expired and unlabeled food items |
Inspection Report
Routine
Deficiencies: 16
Date: Nov 1, 2024
Visit Reason
Routine inspection of Pruitthealth - Magnolia Manor nursing home to assess compliance with regulatory requirements including resident care, safety, and facility conditions.
Findings
The facility was found deficient in multiple areas including failure to maintain resident rights and dignity, medication management, care planning, environment safety, grievance process, PASARR screening, ADL care, vision and mental health services, infection control, food safety, respiratory care, and fall prevention. Several residents did not receive appropriate care or services as required.
Deficiencies (16)
F 0550: Facility failed to ensure removal of facial hair upon resident request, violating resident dignity and rights.
F 0554: Facility failed to prevent storage of unauthorized and expired medications at bedside, risking resident safety.
F 0578: Facility failed to provide residents written information about their rights to accept or refuse medical or surgical treatment for four residents.
F 0584: Facility failed to maintain a safe, clean, and homelike environment including stained pillows, trip hazards from electrical sockets, cracked toilet, and unsanitary water fountains.
F 0585: Facility failed to ensure residents were informed of grievance official and grievance process, limiting resident knowledge of rights.
F 0645: Facility failed to submit PASARR Level II applications for five residents with mental health diagnoses, risking lack of specialized services.
F 0656: Facility failed to develop and implement comprehensive care plans for five residents including ADL, psychiatric, and vision services.
F 0677: Facility failed to provide adequate ADL care including missed showers, incontinence care, and fingernail hygiene for six residents.
F 0685: Facility failed to assist two residents in gaining access to vision services, resulting in uncorrected vision problems.
F 0688: Facility failed to follow occupational therapy restorative nursing program for splint application for one resident, risking contracture progression.
F 0689: Facility failed to ensure environment free from accident hazards including unsecured oxygen tank, aerosol cans in resident room, and inadequate fall prevention supervision for three residents.
F 0692: Facility failed to provide evidence of nutrition assessments by registered dietitian for three residents with weight loss.
F 0695: Facility failed to ensure oxygen therapy equipment was properly maintained and used, including uncovered tubing and masks resting on floor for two residents.
F 0740: Facility failed to provide necessary behavioral health care and services for three residents with mental health diagnoses.
F 0812: Facility failed to procure food from approved sources, failed to discard expired items, failed to label and date food items, and failed to ensure sanitary food delivery practices.
F 0880: Facility failed to maintain infection prevention and control practices including improper medication administration hygiene, contaminated PPE cart, and dirty IV tubing in resident rooms.
Report Facts
Residents sampled: 28
Residents affected by facial hair deficiency: 1
Residents affected by medication storage deficiency: 1
Residents affected by advance directive deficiency: 4
Residents affected by environment deficiency: 1
Residents affected by grievance deficiency: 7
Residents affected by PASARR deficiency: 5
Residents affected by care plan deficiency: 5
Residents affected by ADL care deficiency: 6
Residents affected by vision services deficiency: 2
Residents affected by mental health services deficiency: 3
Residents affected by food safety deficiency: 89
Residents affected by infection control deficiency: 4
Residents affected by fall risk deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN MM | Licensed Practical Nurse | Named in infection control deficiency related to fingerstick blood sugar procedure |
| CNA AA | Certified Nursing Assistant | Named in food delivery and fall prevention deficiencies |
| LPN RR | Licensed Practical Nurse | Named in oxygen safety deficiency |
| DHS | Director of Health Services | Named in multiple findings including oxygen safety, care planning, and mental health services |
| SSD | Social Services Director | Named in mental health services and grievance process deficiencies |
| RN CC | Unit Manager/Register Nurse | Named in ADL care and food delivery deficiencies |
| CNA QQ | Certified Nursing Assistant | Named in ADL care and vision services deficiencies |
| RN EE | Registered Nurse | Named in infection control deficiencies |
| DM | Dietary Manager | Named in food safety deficiencies |
| RD WW | Registered Dietitian | Named in nutrition assessment deficiencies |
Inspection Report
Life Safety
Census: 90
Capacity: 100
Deficiencies: 7
Date: Oct 30, 2024
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with several fire safety requirements including improper operation of self-closing doors, improper installation and maintenance of the fire alarm system, inadequate maintenance of the fire sprinkler system, improper installation and maintenance of electrical components, and lack of thermostatic documentation for portable space heaters.
Deficiencies (7)
Self-closing doors near the kitchen and Pantry were propped open, failing to ensure proper operation.
Fire alarm system installation was improper; circuit breaker not locked in 'on' position, not labeled correctly, and location not identified.
Fire alarm system showed a trouble signal indicating failure in maintenance and operation.
Fire sprinkler system was not properly maintained; sprinkler heads were dusty and missing escutcheon rings near Rooms 301 and 303.
A junction box in the Pantry was missing its cover, indicating improper installation of electrical components.
Electrical panels were blocked but were corrected during the survey.
A portable space heater was present in the Dietary Director's Office without thermostatic documentation.
Report Facts
Certified beds: 100
Census: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to door operation, fire alarm system issues, sprinkler system maintenance, electrical issues, and space heater documentation during the inspection. |
Inspection Report
Abbreviated Survey
Census: 91
Deficiencies: 0
Date: Aug 21, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate a complaint (GA00245561).
Complaint Details
Complaint GA00245561 was investigated and found to be unsubstantiated.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the survey.
Report Facts
Census: 91
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 3, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - MAGNOLIA MANOR following a survey completed on April 3, 2024.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Re-Inspection
Census: 86
Deficiencies: 0
Date: Apr 3, 2024
Visit Reason
A revisit survey was conducted on April 3, 2024 to verify correction of deficiencies cited during the February 7, 2024 Complaint Survey.
Complaint Details
The revisit survey was conducted following a complaint survey on February 7, 2024; all deficiencies from that complaint survey were corrected.
Findings
All deficiencies cited as a result of the February 7, 2024 Complaint Survey were found to be corrected.
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 3
Date: Feb 7, 2024
Visit Reason
A State Licensure survey was conducted due to allegations of exploitation and mismanagement of residents' personal property and finances, including missing cash from residents' trust funds and failure to follow grievance procedures.
Complaint Details
The investigation was triggered by complaints of missing cash from two residents' trust funds. Law enforcement was involved regarding stolen money. The facility was found to have failed to secure residents' money and failed to properly investigate grievances related to these issues.
Findings
The facility failed to protect two residents from exploitation of their cash money locked in a facility safe, failed to properly manage and document residents' financial transactions, and did not follow grievance procedures for resident concerns. Missing cash amounts were identified and refunds were issued or planned.
Deficiencies (3)
Failure to protect two residents from exploitation of their cash money locked in a facility safe.
Failure to include cash transactions and properly manage resident trust accounts for two residents.
Failure to follow grievance procedures and investigate resident concerns presented in resident council meetings.
Report Facts
Facility census: 93
Missing cash amount for Resident 1: 1500
Missing cash amount for Resident 2: 1157
Refund amount for Resident 1: 1650
Refund amount for Resident 2: 800
Total cash payments by Resident 1: 11428
Private room difference payments by Resident 1: 4250
Medicaid payments for Resident 1: 7078
Resident 1 patient liability for March and April 2023: 1330.48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN AA | Registered Nurse, Nurse Navigator (Case Manager) | Named in findings related to handling and discovery of missing resident money |
| LPN BB | Licensed Practical Nurse | Named as key holder to facility safe and involved in discovery of missing money |
| Administrator | Facility Administrator | Named in interviews regarding awareness of missing money and grievance process |
| Former Financial Counsel | Named in interviews regarding handling of resident cash and trust fund procedures | |
| Social Services Assistant CC | Social Services Assistant | Present during observation of facility safe and handling of resident money |
| Social Services Assistant DD | Social Services Assistant | Involved in reporting missing money and notifying Administrator |
| Activity Director | Activity Director | Named in grievance process and resident council meetings follow-up |
| Social Worker | Social Worker for Long-Term Care (LTC) unit | Named in grievance process follow-up and documentation |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 4
Date: Feb 7, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaints regarding resident trust fund management, grievances, and exploitation of resident property.
Complaint Details
The investigation was initiated due to multiple complaints (GA00231198, GA00231296, GA00234469, GA00237734, GA00239634, GA239641, GA00239762, GA00240445, and GA00240716). Some complaints were unsubstantiated, some substantiated without deficiencies, and one complaint (GA00239634) was substantiated with deficiencies cited.
Findings
The facility failed to properly account for resident cash transactions and trust accounts, did not follow grievance procedures for resident concerns, and failed to protect residents from exploitation of their cash money kept in the facility safe. Additionally, the facility delayed reporting a theft of resident funds to the State Agency.
Deficiencies (4)
Failed to include cash transactions for one resident and failed to open and put cash into a trust account for another resident.
Failed to ensure residents' concerns presented in resident council meetings were followed through the grievance process and failed to file a grievance and investigate for one resident after being informed by another state office.
Failed to protect two residents from exploitation of their cash money locked in a facility safe.
Failed to timely report a reasonable suspicion of a crime involving resident money stolen from the facility safe to the State Agency.
Report Facts
Resident census: 93
Cash payments total: 4250
Medicaid payments total: 7078
Resident 1 overpayment refund: 1650
Resident 1 refund entitlement: 2138.02
Missing cash Resident 1: 1500
Missing cash Resident 2: 840
Late reporting days: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN AA | Registered Nurse, Nurse Navigator (Case Manager) | Discovered missing resident money in safe and reported to law enforcement |
| LPN BB | Licensed Practical Nurse | Had key to safe and discovered missing money during surveyor request |
| Administrator | Facility Administrator unaware of cash payments and missing money until survey; responsible for grievance process and reporting | |
| Former Financial Counsel | Handled Resident 1's cash money and placed it in envelope in safe | |
| Social Services Assistant CC | Involved in discovery and reporting of missing resident money | |
| Social Worker | Social Worker for Long-Term Care unit | Reported only one grievance form completed from resident council meetings |
| Activity Director | Responsible for documenting resident concerns and forwarding grievances |
Inspection Report
Routine
Census: 93
Deficiencies: 3
Date: Feb 7, 2024
Visit Reason
A State Licensure survey was conducted at PruittHealth Magnolia Manor from January 23, 2024 through February 7, 2024 to assess compliance with state health regulations.
Findings
The survey revealed multiple deficiencies including failure to protect residents from financial exploitation, improper management of resident trust funds, failure to issue proper financial statements, and inadequate grievance procedures. Two residents were found to have missing cash money from facility safes, and grievances raised by residents were not properly investigated or followed up.
Deficiencies (3)
Failure to protect two residents from exploitation of their cash money locked in a facility safe.
Failure to include cash transactions and to open and put cash into a trust account for residents.
Failure to ensure residents' concerns presented in resident council meetings were followed through the grievance process and failure to file and investigate grievances for one resident.
Report Facts
Facility census: 93
Missing cash amount for Resident 1: 1500
Missing cash amount for Resident 2: 1157
Refund amount for Resident 1: 1650
Refund amount for Resident 2: 800
Private room payment receipts total: 4250
Medicaid payments total: 7078
Resident 1 patient liability: 881
Resident 1 refund entitlement: 2138.02
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN AA | Registered Nurse, Nurse Navigator (Case Manager) | Named in relation to discovery of missing resident money and handling of resident funds |
| LPN BB | Licensed Practical Nurse | Named as one of two people with key to facility safe and involved in discovery of missing resident money |
| Administrator | Facility Administrator | Named in relation to knowledge and response to missing resident funds and grievance process |
| Former Financial Counsel | Named in relation to handling resident cash and trust fund procedures | |
| Social Services Assistant CC | Social Services Assistant | Named in relation to facility safe location and resident money |
| Social Services Assistant DD | Social Services Assistant | Named in relation to reporting missing resident money and grievance follow-up |
| Activity Director | Activity Director | Named in relation to grievance documentation and resident council meetings |
| Social Worker | Social Worker for Long-Term Care unit | Named in relation to grievance process and follow-up |
Inspection Report
Routine
Census: 93
Deficiencies: 3
Date: Feb 7, 2024
Visit Reason
A State Licensure survey was conducted at PruittHealth Magnolia Manor from January 23, 2024 through February 7, 2024 to assess compliance with state health regulations.
Findings
The survey revealed multiple deficiencies including failure to protect residents from financial exploitation, improper management of resident trust funds, failure to issue proper financial statements, and inadequate grievance procedures. Two residents had missing cash from facility safes, and the facility failed to properly investigate and resolve resident grievances.
Deficiencies (3)
Failure to protect two residents from exploitation of their cash money locked in a facility safe.
Failure to include cash transactions and to open and manage resident trust fund accounts properly for two residents.
Failure to ensure residents' concerns presented in resident council meetings were followed through the grievance process and failure to file and investigate grievances for one resident.
Report Facts
Facility census: 93
Missing cash amount for Resident 1: 1500
Missing cash amount for Resident 2: 1157
Refund amount for Resident 1: 1650
Refund amount for Resident 2: 800
Total cash payments for private room difference: 4250
Medicaid payments: 7078
Resident 1 liability: 881
Resident 1 refund entitlement: 2138.02
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Registered Nurse (RN) Nurse Navigator (Case Manager) | Named in findings related to missing resident money and investigation |
| BB | Licensed Practical Nurse (LPN) | Named as key holder to facility safe and involved in discovery of missing resident money |
| CC | Social Services Assistant | Present during observation of facility safe and resident money |
| DD | Social Services Assistant | Involved in reporting missing resident money to Administrator |
| M | Family member | Provided interview regarding missing resident money and lack of financial statements |
| Administrator | Facility Administrator | Named in interviews regarding awareness of missing money and grievance process |
| Former Financial Counsel | Interviewed regarding handling of resident cash payments and trust fund procedures | |
| Activity Director | Interviewed regarding grievance process and resident council meetings | |
| Social Worker | Social Worker for Long-Term Care (LTC) unit | Interviewed regarding grievance form completion and follow-up |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 4
Date: Feb 7, 2024
Visit Reason
The inspection was conducted based on complaints regarding improper handling of residents' personal money, failure to follow grievance procedures, and suspected exploitation and theft of resident funds.
Complaint Details
The investigation was complaint-driven, focusing on allegations of mishandling of resident funds, failure to investigate grievances, exploitation of resident money, and delayed reporting of suspected theft. The complaint was substantiated with findings of missing resident funds and procedural failures.
Findings
The facility failed to properly manage residents' personal funds, including undocumented cash transactions and missing money from resident trust accounts. The grievance process was not properly followed for resident concerns. The facility also failed to timely report suspected theft and exploitation of resident funds to authorities.
Deficiencies (4)
F 0568: The facility failed to properly hold, secure, and manage residents' personal money, including failure to document cash transactions and failure to establish trust accounts for resident funds.
F 0585: The facility failed to honor residents' rights to voice grievances without discrimination and failed to follow through on grievance investigations for resident concerns.
F 0602: The facility failed to protect residents from exploitation of their cash money locked in the facility safe, resulting in missing funds.
F 0609: The facility failed to timely report suspected abuse, neglect, or theft of resident funds to proper authorities, reporting the incident eight days late.
Report Facts
Facility census: 93
Resident 1 overpayment refund amount: 2138.02
Missing cash amount for Resident 1: 1500
Missing cash amount for Resident 2: 997
Late reporting days: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN AA | Nurse Navigator (Case Manager) | Discovered missing resident money in safe and reported to law enforcement |
| LPN BB | Licensed Practical Nurse | Had key to safe and reported missing money discovery |
| Administrator | Was informed of missing money and responsible for reporting to authorities | |
| Former Financial Counsel | Handled resident cash and placed money in envelope in safe | |
| Social Services Assistant CC | Present during safe observation and involved in missing money reporting | |
| Activity Director | Responsible for documenting resident grievances and follow-up | |
| Social Worker | Long-Term Care (LTC) unit | Reported only one grievance form completed from resident council meetings |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 28, 2022
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - MAGNOLIA MANOR, summarizing deficiencies identified during a regulatory inspection.
Findings
The report contains a summary statement of deficiencies identified at the facility; however, no specific deficiencies or severity levels are detailed on this page.
Inspection Report
Re-Inspection
Census: 80
Deficiencies: 0
Date: Oct 28, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the August 25, 2022 Recertification Survey.
Findings
All deficiencies cited as a result of the August 25, 2022 Recertification Survey were found to be corrected.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 14, 2022
Visit Reason
An abbreviated survey was conducted to investigate complaint #GA00226348 from September 12 to September 14, 2022.
Complaint Details
Complaint #GA00226348 was investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Routine
Deficiencies: 4
Date: Aug 25, 2022
Visit Reason
Routine inspection of Pruitthealth - Magnolia Manor nursing home to assess compliance with care plan development, oxygen administration, and safety standards.
Findings
The facility failed to develop and update comprehensive care plans for one resident receiving IV antibiotics and for indwelling catheter usage. Oxygen tanks were found unsecured in three residents' rooms, and one resident receiving oxygen therapy lacked a physician's order for oxygen.
Deficiencies (4)
F 0656: The facility failed to develop a comprehensive person-centered care plan with measurable goals and interventions for one resident receiving intravenous antibiotics.
F 0657: The facility failed to update the care plan to reflect removal of an indwelling urinary catheter for one resident.
F 0689: The facility failed to ensure oxygen tanks were secured in three residents' rooms, posing accident hazards.
F 0695: The facility failed to obtain a physician's order for oxygen therapy for one resident receiving oxygen.
Report Facts
Residents receiving oxygen: 18
Residents sampled for care plans: 35
Residents affected: 1
Residents affected: 1
Residents affected: 3
Resident affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Health Services | Interviewed regarding missing care plans and oxygen orders | |
| Licensed Practical Nurse AA | Confirmed observation of unsecured oxygen tank in resident room | |
| Licensed Practical Nurse BB | Confirmed observation of unsecured oxygen tank in resident room | |
| Administrator | Confirmed expectation for nursing staff to follow oxygen storage policy |
Inspection Report
Renewal
Deficiencies: 2
Date: Aug 25, 2022
Visit Reason
A Licensure Survey was conducted from August 23, 2022 through August 25, 2022 to assess the facility's compliance with licensure requirements.
Findings
The facility was found not in substantial compliance due to failure to develop and update a comprehensive person-centered care plan for one resident receiving intravenous antibiotics and related to indwelling catheter usage.
Deficiencies (2)
Failure to develop a comprehensive person-centered care plan with goals and interventions for one resident receiving intravenous antibiotics.
Failure to update care plan for one resident related to indwelling catheter usage.
Report Facts
Residents reviewed for care plans: 35
Mental status (BIMS) score: 15
IV antibiotic order start date: Aug 5, 2022
IV antibiotic order end date: Aug 8, 2022
IV antibiotic order revised end date: Sep 4, 2022
Care plan start date for indwelling catheter: Aug 5, 2022
Care plan end date for indwelling catheter: Sep 5, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Health Services | Interviewed and confirmed lack of care plan for IV antibiotic infusion and catheter updates for resident #81 |
Inspection Report
Routine
Census: 85
Deficiencies: 8
Date: Aug 25, 2022
Visit Reason
A standard survey was conducted from August 23, 2022 to August 25, 2022 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including comprehensive care planning, oxygen tank safety, enteral feeding management, respiratory care orders, food safety, and equipment maintenance.
Deficiencies (8)
Failed to develop a comprehensive person-centered care plan with goals and interventions for one resident receiving intravenous antibiotics.
Failed to update care plan for one resident related to indwelling catheter usage after catheter removal.
Failed to ensure oxygen tanks were secured in three residents' rooms.
Failed to obtain a physician's order for oxygen therapy for one resident receiving oxygen.
Failed to maintain cleanliness and sanitation of the ice machine, with visible residue inside and outside the machine.
Failed to label enteral feeding bags and syringes with date, time, content, and resident name consistently.
Failed to maintain all dietary equipment in safe operating condition; steamer leaked hot water and steam onto floor.
Failed to procure, store, prepare, and serve food in accordance with professional food safety standards.
Report Facts
Resident census: 85
Residents receiving oxygen: 18
Residents receiving oral diet: 83
Residents reviewed for care plans: 35
Feeding pump rate: 50
Flush volume: 175
Steamer service date: Aug 15, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Health Services | Director of Health Services | Confirmed lack of care plan for IV antibiotic infusion and oxygen order absence |
| Licensed Practical Nurse AA | Licensed Practical Nurse | Confirmed oxygen tank storage issues in resident rooms |
| Licensed Practical Nurse BB | Licensed Practical Nurse | Confirmed oxygen tank storage issues in resident rooms |
| Dietary Aide CC | Dietary Aide | Reported ice machine cleaning and steamer leak notification |
| Dietary Manager | Dietary Manager | Reported steamer leaking water and lack of repair |
| Maintenance Director | Maintenance Director | Aware of steamer leak but did not repair; responsible for equipment maintenance |
| Administrator | Administrator | Confirmed ice machine and steamer issues and expectations for correction |
Inspection Report
Life Safety
Census: 85
Capacity: 100
Deficiencies: 0
Date: Aug 23, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety and emergency preparedness regulations at Pruitt Health Magnolia Manor.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Subpart 483.90(a), Life Safety from Fire, and the related NFPA 101 Life Safety Code 2012 edition. The Emergency Preparedness Program was also reviewed and found compliant with 42 CFR & 483.70.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 28, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00218395 and GA00218569.
Complaint Details
The survey investigated complaints GA00218395 and GA00218569 which were unsubstantiated.
Findings
The complaints were found to be unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 0
Date: Aug 4, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint survey investigating complaints #GA00215535 and GA00215578.
Complaint Details
Complaints #GA00215535 and GA00215578 were investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The complaints were unsubstantiated and no regulatory violations were cited. The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices for COVID-19.
Report Facts
Complaint numbers: 2
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 10, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00211530, #GA00211570, and #GA00211864.
Complaint Details
Complaints #GA00211530, #GA00211570, and #GA00211864 were investigated and found to be unsubstantiated with no regulatory violations.
Findings
The complaints investigated were unsubstantiated with no regulatory violations found.
Inspection Report
Routine
Census: 62
Deficiencies: 0
Date: Dec 23, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 62
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 19, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00204930, #GA00204940, #GA00205924, #GA00206484, and #GA00207161.
Complaint Details
Complaints #GA00204930, #GA00204940, #GA00205924, #GA00206484, and #GA00207161 were investigated and found to be unsubstantiated.
Findings
All complaints investigated were found to be unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Routine
Census: 76
Deficiencies: 0
Date: Aug 5, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted on August 4-5, 2020 by Ascellon on behalf of the Georgia Department of Community Health.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total Census: 76
Inspection Report
Abbreviated Survey
Census: 77
Deficiencies: 0
Date: Jul 15, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and has implemented the recommended practices to prepare for COVID-19.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 26, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the June 20, 2019 Standard Survey.
Findings
All deficiencies cited as a result of the June 20, 2019 Standard Survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 7, 2019
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The follow-up survey noted that all previously cited survey tags have been corrected.
Inspection Report
Deficiencies: 3
Date: Jun 20, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care plans, staff qualifications, and food service management at Pruitthealth - Magnolia Manor.
Findings
The facility failed to develop a complete care plan for respiratory diagnoses and oxygen therapy for one resident. The Dietary Manager was not certified as required. The facility also failed to honor food preferences for one resident during breakfast service.
Deficiencies (3)
F 0656: The facility failed to develop and implement a complete care plan for respiratory diagnoses and oxygen therapy for one resident (#35).
F 0801: The facility failed to ensure the Dietary Manager was certified or had a similar food service management certification.
F 0806: The facility failed to provide food that accommodated resident allergies, intolerances, and preferences for one resident (#5).
Report Facts
Residents sampled: 25
Residents affected: 1
Residents affected: 1
Residents receiving oral diet: 85
Total residents: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Named in deficiency for lack of certification and food preference management |
| Director of Nursing | Director of Nursing | Confirmed lack of respiratory care plan for resident #35 |
| Administrator | Administrator | Confirmed Dietary Manager was not certified and discussed certification expectations |
Inspection Report
Life Safety
Census: 86
Capacity: 100
Deficiencies: 1
Date: Jun 17, 2019
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with fire safety regulations and the National Fire Protection Association (NFPA) standards.
Findings
The facility was found not in substantial compliance with NFPA 25 requirements for maintenance and testing of the fire sprinkler system. Specifically, the fire sprinkler system risers were yellow tagged due to malfunctioning air maintenance devices, which were replaced prior to the survey.
Deficiencies (1)
Fire sprinkler system was not maintained in accordance with NFPA 25 due to malfunctioning air maintenance device and system accelerator.
Report Facts
Census: 86
Total Capacity: 100
Date sprinkler system yellow tagged: May 22, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding fire sprinkler system maintenance |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 7, 2019
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00194925.
Complaint Details
Complaint GA00194925 was investigated and found to be unsubstantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was unsubstantiated and no deficiencies were cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 2, 2019
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00193507.
Complaint Details
Complaint GA00193507 was investigated and found to be unsubstantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was unsubstantiated and no deficiencies were cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 20, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00191317.
Complaint Details
Complaint GA00191317 was investigated and found to be unsubstantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was unsubstantiated and no deficiencies were cited.
Inspection Report
Re-Inspection
Census: 92
Deficiencies: 0
Date: Jun 5, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the April 5, 2018 Recertification Survey.
Findings
All deficiencies cited during the April 5, 2018 Recertification Survey were found to be corrected.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 24, 2018
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00188809.
Complaint Details
Complaint GA00188809 was investigated and found to be unsubstantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was unsubstantiated and no deficiencies were cited.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 23, 2018
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor during the follow-up visit.
Inspection Report
Life Safety
Census: 89
Capacity: 100
Deficiencies: 2
Date: Apr 3, 2018
Visit Reason
A Life Safety Code Survey was 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 due to failure to properly maintain the sprinkler system and smoke/fire barriers, including HVAC ductwork supported by sprinkler piping and unsealed fire barrier penetrations, placing residents at risk in the event of fire.
Deficiencies (2)
Sprinkler system maintenance and testing not properly conducted; HVAC ductwork supported by sprinkler piping in multiple attic locations.
Failure to properly maintain smoke/fire barriers; three of seven fire barriers have penetrations not properly sealed with a listed fire stop system.
Report Facts
Residents at risk: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and discovery |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 14, 2017
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00178427.
Complaint Details
Complaint GA00178427 was investigated and found not substantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was not substantiated and no deficiencies were cited.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 10, 2017
Visit Reason
A follow-up survey was conducted on 7/10/17 to the recertification survey to verify correction of previous deficiencies.
Findings
All deficiencies identified in the prior recertification survey were corrected at the time of this follow-up survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 10, 2017
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 5, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00175727 to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00175727 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Routine
Census: 96
Deficiencies: 2
Date: May 18, 2017
Visit Reason
A standard survey was conducted at Pruitthealth Magnolia Manor from 5/15/2017 through 5/18/2017 to assess compliance with Medicare/Medicaid regulations for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance due to inaccurate coding of Minimum Data Set (MDS) assessments for two residents, specifically errors in coding bladder function and dialysis services.
Deficiencies (2)
Failure to accurately code the bladder function status on the admission and subsequent MDS assessments for Resident #53.
Failure to accurately code dialysis services in Section O of the MDS for Resident #159.
Report Facts
Resident census: 96
Sample size: 30
Civil money penalty: 1000
Civil money penalty: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS nurse AA | Interviewed regarding incorrect coding of MDS assessments for Residents #53 and #159 | |
| MDS nurse BB | Interviewed regarding incorrect coding of MDS assessments and stated corrections would be made |
Inspection Report
Life Safety
Census: 99
Capacity: 100
Deficiencies: 1
Date: May 17, 2017
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with fire safety regulations and related National Fire Protection Association (NFPA) standards.
Findings
The facility was found not in substantial compliance due to a failure to ensure that the kitchen dry storage closet door closure could engage to keep the door closed, which could place 30% of residents at risk in an emergency.
Deficiencies (1)
The kitchen dry storage room door failed to seal due to floor buckling underneath the door, preventing the closure from engaging.
Report Facts
Census: 99
Total Capacity: 100
Percentage of residents at risk: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Accompanied tour during which door closure deficiency was observed |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 11, 2017
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint numbers GA00164554 and GA00168098.
Complaint Details
The survey investigated two complaints, GA00164554 and GA00168098, both of which were unsubstantiated.
Findings
Both complaints investigated during the survey were found to be unsubstantiated.
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