Magnolia Gardens

The facility failed to ensure that exit doors accessible to residents who are confused or disoriented had working, audible door alarms. Specifically, three exit doors were observed where no audible sound occurred when the doors were opened or closed, despite the presence of sensors.

The facility failed to ensure that three exit doors accessible to residents assessed as confused or disoriented had working door alarms with sufficient volume. Observations revealed unlocked doors with no audible sound upon opening, and sensors that did not trigger an alarm. Additionally, one instance was noted where an alarm sounded continuously and required manual intervention to stop.

The facility failed to provide adequate supervision for a resident with cognitive impairment and mobility needs. This resulted in the resident falling from their wheelchair and being found outside the facility in an enclosed courtyard without staff knowledge.

The facility failed to provide timely feeding assistance to a resident needing help with eating. Staff members left the resident unattended with food in front of her to assist others or clear plates, resulting in a delay in meal consumption.

The facility failed to provide timely feeding assistance to a resident with diagnoses including dysphagia and Alzheimer's disease. During breakfast observations, a personal care aide was present but did not begin assisting the resident with their meal immediately upon receipt of the food.

The facility failed to ensure that exit doors were equipped with functioning sounding devices and that wander protection bracelets were in proper working order for residents with dementia or Alzheimer's. Specifically, an exit door in the Special Care Unit was found with the alarm key in the 'off' position.

The facility failed to ensure that one of six sampled staff members was tested for tuberculosis disease upon hire. While documentation existed from a previous employer, the results were not interpreted or documented by a nurse at the facility.