Magnolia Manor

In the surveyor’s words

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

• Immediate jeopardy, isolatedF607Mar 11, 2025

  Based on interview and record review, the facility failed to implement the written abuse policy to ensure an allegation of sexual abuse was reported immediately to the Abuse Coordinator, State Agency, and implement measures to ensure residents were protected from further abuse after an allegation of abuse for 1 of 20 residents (Resident #10) reviewed for allegations of abuse. 1. The facility failed to ensure CNA K was suspended/terminated or removed from working with all residents after a sexual abuse allegation was reported on 01/11/2025. 2. The facility failed to immediately report the sexual abuse allegation to the Abuse Coordinator. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 01/11/2025 and ended on 01/18/2025. […]

• Immediate jeopardy, isolatedF609Mar 11, 2025

  Based on observation, interview, and record review the facility failed to ensure allegations of abuse to the abuse coordinator, allegations of abuse were reported to the state agency within the required 2 hour timeframe, and allegations of misappropriation were reported to the state agency within the required 24 hour timeframe for 6 of 20 residents reviewed for freedom from abuse, neglect, and exploitation/ misappropriation. (Residents #1, #2, #3, #4, #5, and #10) 1. The facility failed to report a sexual abuse allegation immediately to the Abuse Coordinator. LPC J and LVN E did not immediately report, to the Abuse Coordinator, when Resident #10 reported a sexual abuse allegation on CNA K. This non-compliance was identified as past non-compliance. […]

• Actual harm, patternF697Mar 11, 2025

  Based on interview and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 (Resident #7) residents reviewed for pain. The facility failed to administer Resident #7 pain medication for a complaint of pain intensity level of 10 (worst pain possible) out of 10 on [DATE] and pain intensity level of 8 (severe pain) out of 10 on [DATE] due to facility did not have Resdient #7's ordered pain medication available. This failure could place residents at risk for increased pain and decreased quality of life. […]

• Actual harm, isolatedF580Mar 11, 2025

  Based on interview and record review, the facility failed to consult with the resident's physician when there was a need to alter treatment for 1 of 5 residents (Resident #7) reviewed for physician notification with changes in condition. 1. The facility failed to notify the physician of Resident #7 not having pain medications available at the facility when he was admitted on [DATE] with diagnoses of pain and orders for oxycodone for pain. 2. The facility failed to notify Resident #7's physician on [DATE] when he had a change in condition with unmanageable pain when he complained of excruciating pain (scaled 10 out of 10). […]

• No harm, potential for more than minimal, widespreadF812Jul 2, 2025

  Based on observation, interview, and record review, the facility failed to properly store, prepare, distribute, and serve food in accordance with the professional standards for food service safety 1 of 1 kitchen reviewed for safety requirements. 1. The facility failed to ensure foods were sealed and/or labeled properly in freezer and dry storage. 2. The facility failed to ensure food items in the dry pantry were labeled, dated, sealed, and not expired. 3. The facility failed to ensure dented cans in the dry pantry were not stored and co-mingled with non-dented food cans ready for use. […]