Magnolia Gardens Convalescent Hospital

In the surveyor’s words

From the most serious findings on record at Magnolia Gardens Convalescent Hospital, in the surveyor’s own words.

• Immediate jeopardy, patternF684Apr 7, 2021

  Based on interview and record review, the facility failed to provide necessary care and services in accordance with its policy and procedure and professional standards of practice for one of three sampled residents (Resident 1) by: 1. Failing to ensure that Registered Nurse 1 (RN1) verified that the discharge instructions (paperwork including medication list sent to Skilled Nursing Facility 1 [SNF 1] from General Acute Care Hospital 1 [GACH1] belonged to Resident 1 rather than an unknown patient. 2. Failing to ensure that RN 1 verified each medication with Attending Physician 1 (AP1) from SNF 1 upon Resident 1's admission on 2/17/21. 3. […]

• Immediate jeopardy, patternF760Apr 7, 2021

  Based on interview, and record review, the facility failed to administer the correct medications for one of three sampled residents (Resident 1) between 2/17/21 and 2/18/21. This deficient practice resulted in Resident 1 receiving nine medication doses that were intended for an unknown patient and caused Resident 1 to miss a total of 25 intended medication doses between 2/17/21 and 2/19/21. This deficient practice could have resulted in severe health complications possibly leading to hospitalization or death. […]

• No harm, potential for more than minimal, widespreadF880Jan 28, 2021

  Based on observation, interviews, and record review, the facility failed to ensure required Personal Protective Equipment (PPE) was utilized during transport for one of five residents (Resident (R) 4) reviewed for infection control practices. In addition, staff failed to use an Environmental Protection Agency (EPA) approved disinfectant to clean resident restrooms in two of three units (East and Mid Unit) observed for environmental cleaning and disinfection. These failures had the potential to increase the risk of COVID-19 transmission to residents and staff. […]

• No harm, potential for more than minimal, patternF656Jul 21, 2026

  Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for two of five sampled residents (Resident 1 and Resident 3), by failing to: 1. Develop and implement a comprehensive care plan that addressed Resident 1's and Resident 3's indwelling urinary catheter (a flexible tube inserted into the bladder to continuously drain urine, which empties into a collection bag). 2. Develop and implement a comprehensive care plan that addressed Resident 1's back rash. These failures had the potential to result in Resident 1 and Resident 3 not receiving the necessary care and treatment to address their identified conditions.Findings: a. […]

• No harm, potential for more than minimal, patternF726Jul 21, 2026

  Based on interview and record review the facility failed to ensure tracking or other mechanisms were in place to evaluate the effectiveness of training during annual competencies for three of three sampled licensed nurses (Registered Nurse 1 [RN 1]), Licensed Vocational Nurse 1 [LVN 1], and Treatment Nurse [TN 1]) in accordance with facility policy titled, Staffing, Sufficient and Competent Nursing, reviewed on 3/9/2026, by failing to ensure there was documented evidence that a competency assessment had been conducted for licensed nurses on providing indwelling urinary catheter (a flexible tube inserted into the bladder to continuously drain urine, which empties into a collection bag) care.This deficient practice had the potential to result in unrecognized competency deficits and place… […]