Magnolia Healthcare and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF656Feb 23, 2021

  Based on policy review, medical record review, and interview, the facility failed to develop and implement comprehensive Care Plans and interventions that are person-centered that address the needs of 13 of 14 sampled residents (Resident #1, #2, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15) reviewed for wandering behaviors and falls. The facility's failure placed Resident #1, #2, #6, #7, #8, #9, #11, #12, #13, #14, and #15 in Immediate Jeopardy (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). Resident #2, a vulnerable resident with Dementia, eloped from the facility through a window, and staff responded immediately. […]

• Immediate jeopardy, patternF689Feb 23, 2021

  Based on policy review, video camera footage review, National Weather Service statistics, medical record review, observation, and interview, the facility failed to ensure a safe environment, provide adequate supervision to prevent elopement, and failed to investigate elopement incidents for 2 of 10 sampled residents (Resident #1 and #2) reviewed with wandering behaviors and elopement. The facility's failure to ensure a safe environment, provide adequate supervision to prevent elopement, and failure to investigate elopement incidents resulted in Immediate Jeopardy when Resident #2, a vulnerable resident with Dementia, exited the facility through a window, staff responded immediately after he eloped, but did not investigate this incident. […]

• Immediate jeopardy, patternF726Feb 23, 2021

  Based on policy review, employee and contract employee personnel file review, video camera footage review, medical record review, observation, and interview, the facility failed to ensure licensed nurses had the knowledge and skills necessary to provide care and assure safety for 14 of 15 sampled residents (Resident #1, #2, #3, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15) reviewed at risk of falls and/or wandering/elopement. The facility's failure to assess residents, complete fall risk assessments, complete neurological checks, implement appropriate interventions, develop comprehensive Care Plans, and provide care for residents with behaviors resulted in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has… […]

• Immediate jeopardy, patternF835Feb 23, 2021

  Based on policy review, job description review, video camera footage review, medical record review, observation, and interview, facility Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable well-being of the residents. Administration failed to provide oversight, ensure a safe environment, complete a thorough investigation of resident elopements, and conduct a Quality Assurance and Performance Improvement (QAPI) Committee meeting when a resident exited the facility without facility knowledge. […]

• Immediate jeopardy, patternF867Feb 23, 2021

  Based on the policy review, job description review, video camera footage review, medical record review, observation, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns related to falls and elopement/wandering behaviors. The QAPI committee failed to ensure a safe environment, a thorough investigation of resident elopement was completed, and failed to conduct a QAPI committee meeting when residents eloped from the facility without staff knowledge. […]