Magnolia Lane Nursing and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF689Aug 3, 2023

  Based on record review and staff, resident, and Medical Director interviews the facility failed to assist a resident with a transfer from the wheelchair to bed when Nurse Aide (NA) #1 stood behind Resident #4 and allowed the resident to transfer independently. Resident #4's leg slipped, the resident fell on to the bed and experienced shoulder pain. Resident #4 sustained a left humeral head fracture of the shoulder as was noted on the CT (computed tomography) scan on 7/20/2023. This was for 1 of 3 residents reviewed for supervision to prevent accidents. The findings included: Resident #4 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF565Dec 19, 2025

  Based on record review, and resident and staff interviews, the facility failed to communicate the facility's efforts to address concerns and document in writing the facility's response and rationale to concerns voiced during Resident Council meetings for 5 of 10 Resident Council meetings reviewed (January 2025, March 2025, June 2025, July 2025, and August 2025).Findings included:The Resident Council minutes for December 2024 (no day listed) noted that residents voiced a concern regarding the daily menus were not being posted again. The Resident Council minutes for January 2025 (no day listed) revealed residents voiced they had noticed the daily menus were being posted but they would like more variety. […]

• No harm, potential for more than minimal, patternF645Dec 19, 2025

  Based on record review and staff interviews, the facility failed to submit a request for an evaluation for a Level II Preadmission Screening and Resident Review (PASRR) determination for residents who were admitted to the facility with serious mental health disorders for 4 of 4 residents reviewed for PASRR (Resident #37, Resident #7, Resident #52 and Resident #50).Findings included: 1. A PASRR Determination Notification letter dated 07/15/25 revealed Resident #37 had a Level I PASRR with no expiration date. Resident #37 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, post-traumatic stress disorder (PTSD) and bipolar disorder. […]

• No harm, potential for more than minimal, patternF812Dec 19, 2025

  Based on observations and staff interviews, the facility failed to discard food past its use-by date in 1 of 1 walk-in cooler and store food off the floor in 1 of 1 walk-in freezer. These practices had the potential to affect food served to residents. The findings included:a. During an initial observation of the facility's kitchen with the Dietary Manager on 12/15/25 at 9:59 AM, the walk-in cooler had two (2) one-quart sized containers of lemon-flavored thickener with a use-by date of 10/28/25.b. […]

• No harm, potential for more than minimal, patternF812Sep 25, 2024

  Based on observations, record review and staff interviews, the facility failed to dry insulated bases, lids, pans and baking sheets before they were stacked for use, failed to store perishable food off the floor, failed to remove a dented canned good item stored for use, and failed to discard expired food and food items with signs of spoilage stored in 1 of 1 walk-in cooler and main dining room refrigerator. In addition, the facility failed to cover facial hair during food preparations. These practices had the potential to affect food served to residents. The findings included: a. […]