Magnolia Place of Saxonburg

Staff failed to initial the medication administration record at the time of administration for resident #2, and several medications were documented as administered for residents #2 and #3 when they were not actually given.

Staff failed to follow prescriber orders for several medications for residents #2, #3, and #4, including failure to administer prescribed doses on 12/16/25 and 1/3/26.

The medical evaluation for resident #1 was blank in the immunization area.

A resident struck another resident in the head and legs while staff were temporarily out of the room during incontinence care.

The home did not record the evacuation time in minutes and seconds for fire drills conducted on several dates in 2024.

The home failed to alternate exit routes during fire drills from January 2024 through December 2024, consistently using the 'Safe Area' as the exit route.

A resident's bed was missing fitted sheets.

The common bathroom next to the nurse station in the memory care unit had no toilet paper.

The fire safety diagram on the memory care unit incorrectly indicated two sets of double fire safety doors.

An uncovered garbage bag containing refuse was found in the garden unit kitchen.

The fire extinguisher near the laundry room in the memory care unit lacked documentation of an annual inspection.

The support plan for resident #1 did not include care services provided by home health services or how the home would meet the resident's need for wound/skin care.

Staff person smacked a resident on the hand after the resident expressed agitation during care.

Staff person was observed yelling at and physically pulling a resident by the forearm, resulting in a skin tear.