Magnolia Gardens Center for Nursing and Rehabilita

In the surveyor’s words

From the most serious findings on record at Magnolia Gardens Center for Nursing and Rehabilita, in the surveyor’s own words.

• Immediate jeopardy, patternF760Apr 22, 2021

  Based on record review, observation, resident, facility staff, [CONDITION(S)] staff, and physician interviews, the facility failed to prevent significant medication errors for 1 of 8 residents reviewed for medication administration (Resident #42). The facility administered heart medication, insulin, blood thinner, blood pressure and diabetic medications to Resident #42 after Resident #68 ' s medications were transcribed in error for Resident #42. The facility failed to administer prescribed antipsychotic medication, heart medication, pain medication, tremor medication and insulin to Resident #42. Resident #42 had the high likelihood of additional adverse consequences to the medications he received that were not intended for him. […]

• Immediate jeopardy, isolatedF689Jul 18, 2025

  Based on observation, record review, and interviews with facility staff, resident, and the Contracted Van Transportation Company Owner, the facility failed to ensure Resident #1's wheelchair was secure on the contract transportation van lift by the Contract Van Driver before the lift platform was raised to the elevated position. On 3/7/25, Resident #1 was loaded onto the van lift by the Contract Van Driver. The lift was positioned at the rear entrance of the van and Resident #1 was facing out away from the van. When the lift platform was at the floor level of the van, Resident #1's wheelchair rolled forward, away from the van, and Resident #1 fell forward, off of the lift, landing on the asphalt parking lot. […]

• No harm, potential for more than minimal, widespreadF727Nov 18, 2025

  Based on record reviews and staff interviews, the facility failed to provide Registered Nurse (RN) coverage at least 8 consecutive hours per day, 7 days per week for 13 out of 36 days reviewed for staffing (4/27/25, 5/4/25, 5/25/25, 6/1/25, 6/15/25, 6/22/25, 8/23/25, 8/31/25, 9/6/25, 9/7/25, 9/14/25, 9/20/25, and 9/21/25). The findings included:Review of the staffing data submitted by the facility through the CMS (Centers for Medicare and Medicaid Services) Payroll-Based Journal (PBJ) system for quarter 3 (April 1, 2025, through June 30, 2025) indicated there was no RN coverage for eight consecutive hours on 4/27/25, 5/4/25, 5/25/25, 6/1/25, 6/15/25, and 6/22/25. […]

• No harm, potential for more than minimal, widespreadF812Sep 1, 2022

  Based on observations and staff interviews, the facility failed to ensure a potentially hazardous sandwich made with eggs and mayonnaise was stored within safe temperature range at or below 41 degrees Fahrenheit to prevent the potential for food borne illness; failed to ensure the wash and final rinse cycles of the dishwashing machine operated at the manufacturer's recommended temperatures; by not maintaining the food service equipment in clean and debris-free condition; and, failed to ensure the food items stored in the snack/nourishment refrigerators in 1 of 2 residents' nourishment rooms (100 hall nourishment room) were clean, and food items not provided by the facility were dated and labeled. These practices had the potential to affect food served to residents. Findings included: 1. […]

• No harm, potential for more than minimal, widespreadF867Sep 1, 2022

  Based on observations, record review, resident and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey conducted on [DATE]. This was for 14 deficiencies that were cited in the areas of Resident Rights/Exercise of Rights (F550), Safe/Clean/Comfortable/Homelike Environment (F584), Request/Refuse/Discontinue Treatment; Formulate Advance Directives (F578), Medicaid/Medicare Coverage/Liability Notice (F582), Notice Requirements Before Transfer/Discharge (F623), Quarterly Assessments At Least Every 3 Months (F638), Accuracy of Assessments (F641), Develop/Implement Comprehensive Care Plan (F656), Care Plan Timing and… […]