Magnolia Manor Senior Care

Based on documentation review and interview, the manager failed to ensure documentation of medication administration included the name and signature of the individual administering medication for one of of two residents sampled. The deficient practice posed a health and safety risk to a resident if the facility did not properly document medication administration for a resident. Findings include: 1. A review of R2's Medication Administration Record (MAR) revealed no caregiver initials that medication was administered on December 8, 2025, for the evening administration of Atorvastatin 40 mg. 2. A review of the facility's policies and procedures revealed a policy titled "Documenting by Medication Administration Record (MAR) and Assistance." The policy stated, "The facility shall maintain a daily Medication Administration record (MAR) for each resident who receives assistance with self-administration of medications or medication administration. The MAR is the form on which the caregiver will document that medication has been administered to a resident..." 3. In an exit interview, E1 and E2 acknowledged that the MAR was not signed for the aforementioned medication. E2 reported giving the medication but forgot to sign the MAR.

Based on interview and documentation review, the manager of an assisted living home who contacted an emergency responder on behalf of a resident failed to provide a written document with all required information to the emergency responder (EMS). The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. In an interview, E1 reported R2 had an accident, emergency, or injury on October 31, 2025, that resulted in facility personnel contacting EMS on behalf of R2. 2. A review of facility documentation revealed notes that R2 had pulled the nasal tube out of the nose on October 31, 2025. The report identified that 911 was called, and the resident was taken to the hospital. 3. In an interview, when the Compliance Officer requested a copy of the documentation given to EMS in compliance with this statute, E1 reported "resident face sheet and MAR was provided". When the Compliance Officer asked if E1 had a copy of the documentation given to EMS, E1 stated, “No.” When the Compliance Officer asked if facility personnel gave EMS a document in compliance with this statute, E1 stated, “No.”

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for two of four residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R3's medical record revealed a current written service plan for personal care services dated September 29, 2023. This service plan stated "...Elimination: Continent, Check Q 2-4 hours, Dependant with toileting, Disposable underwear..." Review of R3's medical record revealed an "Activities of Daily Living Record" dated October 2023. This record showed incontinence care was provided at 7am, 2pm, and 8pm. However, documentation was not available indicating this service was provided every 2-4 hours per the service plan. 2. Review of R4's medical record revealed a current written service plan for personal care services dated May 24, 2023. This service plan stated "...Elimination: Incontinent bowel/bladder, Check Q 2-4 hours, Dependant with toileting..." Review of R4's medical record revealed an "Activities of Daily Living Record" dated October 2023. This record showed incontinence care was provided at 7am, 2pm, and 8pm. However, documentation was not available indicating this service was provided every 2-4 hours per the service plan. 3. In an interview, E1 acknowledged R3's and R4's medical records did not include documentation of incontinence care per the service plan and reported the service was provided as indicated in the service plan.

Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0 F or below. The deficient practice posed a risk for potential food borne illnesses. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officer observed open containers of Kraft parmesan cheese, Sweet Baby Rays barbecue sauce, Sweet Baby Rays honey mustard, Heinz ketchup, Great Value strawberry preserves, and Great Value ranch dressing stored in the kitchen pantry. These containers stated "Refrigerate after opening". 2. In an interview, E1 and E2 acknowledged the foods were stored in the pantry and required refrigeration.

Based on record review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver immediately notified the resident's primary care provider, for one of one resident reviewed who had an incident resulting in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. Review of R1's medical record revealed a incident report dated June 1, 2023. This document indicated 911 was called, however documentation was not available showing R1's primary care provider was notified of this incident. In addition, R1's medical record revealed a incident report dated July 3, 2023. This document indicated 911 was called, however documentation was not available showing R1's primary care provider was notified of this incident. 2. In an interview, E1 and E2 acknowledged R1's medical record did not include documentation showing a caregiver immediately notified the primary care provider when R1 had an incident resulting in needing medical services.