Magnolia Post Acute Care

In the surveyor’s words

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

• Actual harm, patternF600Dec 11, 2025

  Based on interview and record review, the facility failed to ensure three out of three residents (Resident 1, 2, and 3) were free from sexual abuse when:1. Resident 1 stated certified nursing assistant (CNA) 4 fondled her clitoris and inserted his fingers in her vagina during care.2. Resident 2 stated CNA 4 massaged her vagina during a brief change. 3. Resident 3 stated CNA 4 inserted his fingers into her vagina during a brief change.4. The facility hired CNA 4 with reference checks that reflected negative past employment performance. […]

• No harm, potential for more than minimal, patternF578Aug 29, 2025

  Based on observation, interview, and record review the facility failed to evaluate and/or offered to help formulate (assist) an advanced directive (AD- a legal document indicating resident preference on end-of-life treatment decisions) for three of eight residents (Resident 49, 113 and 114) reviewed.This deficient practice placed all 92 residents at risk of not having their medical care wishes honored in the event of a health emergency or if they become unable to communicate leading to unwanted treatments or confusion about their care preferences.Findings:1. […]

• No harm, potential for more than minimal, patternF802Aug 29, 2025

  Based on observation, interview, and record review the facility failed to ensure the competency of one dishwasher for chlorine testing related to dishware when using the low temperature dishwasher.This failure increased the risk of foodborne illness.Findings:On 8/27/2025 at 8:37 A.M., a concurrent interview with Dietary Aide (DA) 1 and observation of low temperature dishwashing process was conducted. DA 1 stated the process for washing dishes with low temperature washer was as follows: .Rinse dishes of any debris, move load of dishes into washer. Observe rinsing temperature and log once a shift, rinsing temperature needs to be 120 F or greater. After load done check chlorine levels, they should be between 50-100ppm. […]

• No harm, potential for more than minimal, patternF812Aug 29, 2025

  Based on observation, interview, and record review the facility failed to properly cover a caramel (sugar or syrup heated until it turns brown) sauce in the walk-in refrigerator.This failure had the potential for promoting foodborne illnesses.Findings:On 8/27/2025 at 8:37 A.M., a concurrent interview with Dietary Aide (DA) 2 and observation of walk-in refrigerator was conducted. A pre-prepared food covered with wax paper was observed on the 2nd level of the refrigerator. A creamy off-white liquid was observed on top of the wax paper covering the prepared food. DA 2 stated that she had prepared a caramel sauce earlier in the day and had covered it with wax paper to be used later in the day. […]

• No harm, potential for more than minimal, patternF725Jul 15, 2021

  Based on interview and record review, the facility failed to ensure call lights were answered in a timely manner for ten confidential residents (CR- 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10). This failure had the potential to result in residents' needs not being met, which had the potential to result in physical and emotional harm. Findings: On 7/13/21 at 10 A.M., a confidential meeting was conducted. CR 1, 2, 3, 4, 5, 6, 7, 9, and 10 stated it had taken between 20 minutes to two hours for staff to answer call lights, especially on the evening (3 P.M. - 11 P.M.) shift and night (11 P.M. - 7 A.M.) shift. CR 1, 3, 4, 5, 6, 7, 8, 9, and 10 stated the wait time for call lights to be answered was an on-going issue. CR 5 stated the wait for a call light to be answered was one hour. […]