Magnolia Creek Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Magnolia Creek Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Aug 12, 2025

  Based on facility policy review, ANA's [American Nurses Association] Principles for Nursing Documentation, review, job description review, medical record review, Neuro (Neurological) Check Assessment Form review, and interviews the facility failed to ensure treatment and care was provided in accordance with professional standards of practice, the comprehensive care plan and the resident's goals for care. The facility failed to promptly identify and intervene for an acute change in condition for 1 of 3 (Resident #1) sampled residents reviewed for quality of care. The facility's failure to ensure a resident received appropriate assessments and interventions resulted in Immediate Jeopardy when on [DATE] Resident #1 was noted to have a raised area on his left forehead. […]

• Immediate jeopardy, isolatedF678Jun 8, 2023

  Based on policy review, medical record review, observation, and interview, the facility failed to ensure Cardiopulmonary Resuscitation (CPR) was performed for 1 of 10 residents (Resident #1) reviewed for advance directives. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #1 was found unresponsive without respirations and staff failed to perform CPR with chest compressions and artificial respirations per the choice of Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. […]

• Actual harm, isolatedF657Dec 9, 2021

  Based on policy review, medical record review, observation, and interview, the facility failed to revise the Care Plan to reflect the residents' current status for 3 of 27 sampled residents (Resident #11, #20, and #56). The facility's failure to revise the Care Plan with appropriate interventions resulted in actual harm when Resident #56 sustained a fall which resulted in a fracture (broken bone) to the left femur (large upper bone in the leg). Findings include: Review of the facility's policy titled, Falls Management Program Guidelines, dated 12/1/2018, revealed .Should the Resident experience a fall the attending nurse shall complete a post fall assessment. […]

• Actual harm, isolatedF689Dec 9, 2021

  Based on policy review, medical record review, observation, and interview, the facility failed to implement appropriate interventions to prevent falls and injury for 1 of 7 sampled residents (Resident #56) reviewed for accidents. The facility's failure to provide appropriate interventions resulted in actual harm when Resident #56 sustained a fall which resulted in a fracture (broken bone) of the left femur (large upper bone of the leg). The findings include: Review of the facility's policy titled, Falls Management Program Guidelines, dated 12/1/2018, revealed .strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measure .recognizes even the most vigilant efforts may not prevent all falls and injuries. […]

• No harm, potential for more than minimal, widespreadF809Dec 9, 2021

  Based on policy review, observation, and interview, the facility failed to deliver meal trays to residents in a timely manner which resulted in delayed mealtimes on 5 of 5 halls (100 Hall, 200 Hall, 300 Hall, 400 Hall, and the Rehabilitation Hall). This failure had the potential to affect 98 of the 100 residents who received a meal tray. The findings include: Review of the facility's policy titled, Frequency of Meals, dated 7/2017, revealed .Meals will be served .to help assure that residents receive nutritional requirements. […]