The Springs Magnolia

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Feb 18, 2022

  Based on observation, record review, and interview, the facility failed to ensure a newly admitted resident was closely supervised after exhibiting exit-seeking behaviors and verbalizing an intent to leave the facility, to prevent elopement for 1 (Resident #1) of 3 (Residents #1, #2 and #3) sampled residents who were at risk for elopement. The failed practice resulted in past noncompliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, who exited the facility undetected by staff and was found approximately 0.7 miles from facility walking by the side of a busy highway, and had the potential to cause more than minimal harm to 15 residents who were at risk for elopement, as documented on a list provided by the Administrator… […]

• Actual harm, patternF692Mar 21, 2022

  Based on observation, record review and interview, the facility failed to ensure nutritional interventions ordered by the physician or recommended by the Registered Dietitian (RD) were promptly evaluated by the Interdisciplinary Team for appropriateness, developed and initiated, and the RD was promptly consulted for further nutritional recommendations when the resident's weight continued to decline from month to month, in order to minimize further weight loss and maintain nutritional status to the extent possible for 2 (Resident #62 and #64) of 28 (Resident #1, #3, #7, #11, #14, #18, #20, #22, #23, #25, #28, #36, #37, #41, #43, #47, #49, #51, #52, #62, #63, #64, #67, #74, #129, #234, #235, and #239) sampled resident who had experienced a severe weight loss over the last 6 months and failed… […]

• No harm, potential for more than minimal, widespreadF812Jun 8, 2023

  Based on observation and interview, the facility failed to ensure food items stored in the refrigerator were covered and dated, dietary staff washed their hands when contaminated to decrease the potential for food borne illness for residents receiving food from 1 of 1 kitchen, 2 of 2 ice machine were maintained in a clean and sanitary condition and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 71 residents who received meals from the kitchen (total census: 72) as documented on a list provided by the Dietary Supervisor on 06/06/23 at 8:00 AM. The findings are: 1. […]

• No harm, potential for more than minimal, widespreadF812Jan 22, 2021

  Based on observation, record review and interview, the facility failed to ensure food items stored in the refrigerator and freezers were dated when opened, failed to ensure sanitizer levels in the low-temperature dish machine were routinely monitored and documented and failed to ensure dietary staff washed their hands or changed gloves before handling clean equipment or food items to prevent the potential for food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 63 residents who received meals from the kitchen (total census: 68) as documented on a list provided by the Administrator on 01/21/2021. The findings are: 1. […]

• No harm, potential for more than minimal, patternF761Jun 20, 2024

  Based on observation, record review, and interview, the facility failed to ensure 2 (Residents #23 and #49) did not have medications stored at the bedside. The findings are: 1. Review of Resident #23's Medical Diagnosis sheet revealed the resident had diagnoses of heart failure, chronic kidney disease, and type II diabetes mellitus. a. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/16/2024 revealed a Brief Interview for Mental Status (BIMS) score of 11 (8-12 indicates moderate cognitive impairment). b. On 06/17/2024 at 11:12 AM, the Surveyor observed Resident #23 with a 32 ounce open bottle of 0.91% alcohol sitting on the floor, on the left side of the bed. Resident #23 confirmed, I brought the alcohol from home to rub on my knee. c. […]