Magnolia Haven Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Magnolia Haven Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 19, 2022

  Based on interviews, medical record review, review of the facility's policy titled Elopements and Wandering Residents, and review of a facility document summarizing the facility's investigation into Resident Identifier (RI) #1's elopement, facility staff failed to implement the elopement policy after a door alarmed on 08/11/2022, when RI #1 exited a facility door and left the premises. On 08/11/2022 at approximately 5:45 PM Employee Identifier (EI) #4, a Certified Nursing Assistant (CNA), heard the door alarm sound at the Rehab door. EI #4 proceeded to the Rehab door and looked out the window. When EI #4 did not see a resident outside the window, she turned off the door alarm and went back to work on the unit. […]

• Actual harm, isolatedF600Jun 30, 2026

  Based on observation, record review, interviews, and a policy titled .Abuse, Neglect, and Exploitation the facility failed to ensure Resident Identifier (RI) # 90 was free from resident to resident physical abuse perpetrated by RI #57. The facility failed to implement timely and effective interventions to prevent resident to resident abuse on 04/15/2025 after RI #57 complained to staff about RI #90 entering his/her room without permission. On 04/16/2025, RI #57 pushed RI #90 from his/her room into the hallway, causing him/her to fall and sustain a laceration above the left eye and Contrast Tomography (CT) confirmed fractures of the left maxillary sinus wall and left orbital wall.This deficient practice affected RI #90, one of six sampled residents reviewed for abuse.This deficiency was… […]

• No harm, potential for more than minimal, widespreadF801Jun 30, 2026

  Based on interviews, the facility's CERTIFIED DIETARY MANAGER JOB DESCRIPTION, and a certificate of completion for Nutrition and Foodservice Professional Training Pathway III(b) from the University of Florida; the Dietary Supervisor in charge of the facility's Food Service Department/Dietary Department did not meet minimum qualifications as a director of food and nutrition services. This had the potential of affecting 84 of 84 residents receiving meals from the facility's Food Service Department/Dietary Department while it was under the direction of an unqualified individual. Findings Include: The facility's CERTIFIED DIETARY MANAGER JOB DESCRIPTION, dated 5/2003, included the following: . […]

• No harm, potential for more than minimal, widespreadF803Jun 30, 2026

  Based on observations, interviews, the facility's policies for DIET MANUAL and MENUS, the facility's menus for Spring/Summer 2026, and the facility's posted SCOOP AND DIPPER SIZES; the facility failed to ensure a #10 dipper/scoop was used for Chopped Meat (Hamburger Steak) for Lunch on Tues. 6/23/2026, a #6 dipper/scoop was used for Puree Lasagna for Dinner on Tues. 6/23/2026, and a #10 dipper/scoop was used for Chopped Fried Chicken and a #10 dipper/scoop was used for Puree Chicken when serving Lunch on Wed. 6/24/2026. This affected residents receiving chopped meats, Mechanical Soft diets, and Puree diets; 36 of 84 residents receiving meals at the facility and had the potential to result in weight loss. The facility's policy for DIET MANUAL, revised 8/2017, included the following: . […]

• No harm, potential for more than minimal, widespreadF812Jun 30, 2026

  Based on observation, interviews, a repair/service report, and the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code; the facility failed to ensure food was frozen solid in the Reach-in Bread Freezer on 6/22/2026 and further failed to ensure the internal temperature did not reach 45 (degrees) Fahrenheit (F). This had the potential to affect 84 of 84 residents receiving meals from the facility's Food Service Department and possibly exposing them to food borne illness.The 2022 U.S. FDA Food Code included the following: . Temperature and time Control3-501.11 Frozen Food.Stored frozen FOODS shall be maintained frozen.3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding.(A) . […]