Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Magnolia Manor Of Midway during CMS and state inspections, most recent first.
Failure to document vaccine education and consent for flu and pneumococcal immunizations. Record review showed that multiple residents received or were offered flu and pneumococcal vaccines without clear documentation that the resident or RP was provided the risks and benefits before consent, refusal, or administration. Several records also showed incomplete pneumococcal series follow-up, with prior PCV13 or PPSV23 history but no documentation that CDC-recommended PCV15, PCV20, or PCV21 options were offered when indicated. The IP confirmed consents were obtained at admission and were not updated before later vaccine administration.
The facility failed to document that responsible parties were informed of the risks and benefits before consenting to or declining COVID-19 vaccination/booster for several residents. One resident’s responsible party declined without documented education, two residents received the vaccine/booster with the risks and benefits section left blank, and two other residents lacked evidence that their responsible parties were given the opportunity to make an informed decision. The IP confirmed the missing documentation and stated admission consents were not updated before later vaccine administration.
Failure to Prevent Resident-to-Resident Abuse: The facility did not prevent verbal and physical abuse between residents. One resident with severe cognitive impairment was involved in threats to kill another resident and harm the resident’s family, while another resident was observed intentionally striking a different resident during an argument. The facility substantiated both incidents as resident-to-resident abuse, and progress notes reviewed for the incidents contained no documentation.
Failure to Timely Report Alleged Abuse: The facility did not follow its reporting requirements for alleged abuse involving a resident with severe cognitive impairment, a cognitively intact resident, and another resident with severe cognitive impairment. Staff witnessed verbal threats and physical abuse, but the SA did not receive the reports within the required 2-hour timeframe. Interviews showed staff and the DON knew of the incidents, yet reporting was delayed beyond the policy requirement.
The facility failed to include victimization of abuse in the care plans for two residents with severe cognitive impairment. One resident with hemiplegia/hemiparesis, MDD, dementia, and anxiety was threatened by another resident, and another resident with schizophrenia, Alzheimer's disease, dementia, and cognitive communication deficit also had no abuse-related care plan interventions. The DON confirmed the care plans did not address abuse victimization or psychosocial harm.
Failure to update a resident’s care plan after aggressive behavior toward others. The resident had multiple psychiatric and neurologic diagnoses and an existing care plan for verbal behavioral symptoms, but staff documented threats to slap and kill another resident and later an intentional hit to another resident’s arm. The care plan was not revised to reflect current interventions, and the DON confirmed it had not been updated after the incidents.
Failure to Attempt Assistive Device for Contracted Wrist: A resident with hemiplegia/hemiparesis after a CVA had impaired ROM and a contracted right wrist with a closed hand. OT notes showed prior passive stretching and a temporary splint trial, but the resident was later discharged from OT, no orthotic management was provided, and no splint, brace, or other device was in place when the resident was observed in a wheelchair.
Failure to assess bed rail entrapment risk and obtain consent for a resident using bilateral bed rails for mobility assistance. The resident had Alzheimer’s disease, was cognitively intact per BIMS, and used the rails to reposition in bed. The EMR included a prior side rail assessment stating bed rails were not indicated, while the DON stated documentation of the risks/benefits discussion and consent form could not be located.
A resident with a documented allergy to sulfamethoxazole was given Bactrim DS after staff bypassed a safety alert and failed to verify the allergy with the provider. The pharmacy did not flag the order due to incomplete allergy records, and the resident experienced an allergic reaction after receiving multiple doses. Communication and documentation failures among nursing staff and the pharmacy contributed to the incident.
A resident with a seizure disorder was re-admitted from the hospital with new orders for an anticonvulsant and an antibiotic, but these medications were not entered into the EMR or administered. The omission was not identified by nursing or pharmacy staff, and the resident was later rehospitalized for seizure activity due to not receiving the required anticonvulsant.
The facility failed to maintain proper food safety and hygiene standards, as observed during a kitchen tour. The ice machine was dirty, and several food items in the walk-in cooler and freezer were either expired or not properly labeled and dated. Additionally, two dietary cooks were not wearing beard guards in the food preparation area. These deficiencies could potentially affect the 72 residents receiving an oral diet.
The facility failed to ensure privacy during ADL care for a resident with severe cognitive impairment, as privacy curtains were not fully drawn and window blinds were open. Additionally, a resident with a suprapubic catheter did not have a dignity bag covering the drainage bag, as observed on multiple occasions. Staff interviews confirmed these oversights, acknowledging the need for privacy and dignity in resident care.
A facility failed to provide a resident with a suitable chair, leading to improper body alignment, and did not assess two residents for appropriate placement on the Secured Unit. One resident was placed in an incorrect chair, causing discomfort, while two others were inappropriately housed in a unit meant for those with elopement risks, despite lacking such tendencies. Staff interviews revealed a lack of awareness regarding the residents' needs and placement criteria.
The facility failed to maintain a clean environment, with strong urine odors and missing floor tiles in a bathroom on Hall 3, and rust on raised toilet seats in two bathrooms on Hall 2. The Maintenance Director and DON confirmed these issues during a tour, and the Maintenance Director was unaware of the problems due to a lack of work orders. The Housekeeping Supervisor was also unaware of the odor issue, despite having a log for addressing such problems.
The facility failed to develop care plans for two residents, one lacking a plan to prevent future abuse after an altercation, and another without a plan for Restorative Nursing Services despite needing assistance with daily activities. Staff interviews confirmed these omissions.
The facility failed to provide appropriate care for three residents, leading to deficiencies in maintaining or improving their functional abilities. A resident with severe cognitive impairment was placed in an improperly fitted Geri-chair, another resident with intellectual disabilities was left without a footrest in a wheelchair, and a third resident with hemiplegia did not receive necessary restorative care services due to a misunderstanding about hospice care.
The facility failed to safely store personal care items in a shared bathroom, specifically a can of shaving cream, which was accessible to residents. The shaving cream posed a hazard due to its ingredients, with risks of explosion, respiratory issues, and ingestion. The ADON and an LPN confirmed the presence of the shaving cream and acknowledged the high risk of accidental ingestion by residents with low cognition and safety awareness.
A facility failed to ensure staff used PPE for a resident under Enhanced Barrier Precautions. Despite policy requirements, a CNA did not wear PPE during incontinent care, and PPE was not readily available in the resident's room. Staff interviews revealed a lack of focus on PPE use, with the ADON prioritizing privacy issues and the Administrator unaware of the non-compliance. The IPC acknowledged the need for clearer PPE instructions, and the CNA admitted to forgetting PPE use.
Failure to Document Vaccine Education and Consent for Flu and Pneumococcal Immunizations
Penalty
Summary
The facility failed to ensure that residents were offered pneumococcal and flu vaccines and that residents or their representatives were provided the risks and benefits before vaccination decisions were made. Record review showed that R2’s responsible party declined the pneumococcal and flu vaccines at admission, but there was no evidence the risks and benefits were provided before the refusal. R2 had previously received PCV13 outside the facility, and the record did not show that PCV20 or PCV21 was offered to complete the pneumococcal series per CDC guidance. For R6, the record showed the responsible party gave verbal telephone consent for pneumococcal and flu vaccines, but there was no documentation that risks and benefits were provided before the vaccines were given. R6 had received PPSV23 outside the facility before admission, and the record did not show that PCV15, PCV20, or PCV21 was offered to complete the pneumococcal vaccination series. The immunization record also showed the flu vaccine was given, with the risks and benefits section left blank. For R69, R3, and R75, the facility records showed consent forms were present, but the documentation of risks and benefits was incomplete or blank for the flu and/or pneumococcal vaccines. R69 had received PPSV23 at the facility and later received the flu vaccine, with no evidence that PCV15, PCV20, or PCV21 was offered to complete the pneumococcal series. R3 and R75 received PCV20 and flu vaccines, but the risks and benefits section on the preventative health care documentation was blank. The Infection Preventionist confirmed that consents were obtained at admission and that no updated consents were obtained before administration of the flu and pneumococcal vaccines.
COVID-19 Vaccine Consent and Education Documentation Deficiencies
Penalty
Summary
The facility failed to ensure that the responsible party for one resident who declined the COVID-19 vaccine/booster had been informed of the risks and benefits before refusing the vaccine. Record review showed the resident’s vaccination authorization form documented a decline, but there was no evidence in the medical record that the responsible party received the required education before making that decision. The facility also failed to ensure that the responsible parties for two residents who received the COVID-19 vaccine/booster had been provided the risks and benefits before consent was obtained, and failed to ensure that two other residents’ responsible parties were given the opportunity to make an informed decision about vaccination. For one resident, consent was obtained verbally by telephone, but the risks and benefits section was blank; for another, the vaccination authorization and preventive health care documentation showed the booster was given with the risks and benefits section blank. For two additional residents, the vaccination authorization forms were undated or lacked documented evidence that the responsible parties were offered education or the opportunity to decide. The Infection Preventionist confirmed the findings during interview and stated that consents obtained at admission were not updated before later vaccine administration.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse when it did not prevent resident-to-resident verbal and physical abuse involving three sampled residents. The report identified that one resident had diagnoses including hemiplegia, hemiparesis, major depressive disorder, dementia, and anxiety disorder, and had a BIMS score of 7 indicating severe cognitive impairment. Another resident had diagnoses including schizophrenia, Alzheimer’s disease, dementia, and cognitive communication deficit, with a BIMS score of 3 indicating severe cognitive impairment. A third resident had diagnoses including parkinsonism, schizoaffective disorder, bipolar disorder, anxiety disorder, traumatic brain injury, altered mental status, and schizophreniform disorder, and had a BIMS score of 15 indicating cognitive intactness. For one incident, staff documented that two residents were overheard threatening each other, including statements about killing family members and spreading blood so family members would die. The facility’s investigation substantiated resident-to-resident abuse, and interviews confirmed that one resident had bumped the other resident’s bed with a wheelchair and made threats to slit the resident’s throat and harm the resident’s family. The roommate involved was unable to move or defend himself, and staff described the event as verbal abuse. The resident’s progress notes for the period reviewed contained no notes regarding the alleged incident. For another incident, staff observed a resident swing his arm and hit another resident on the arm while the second resident was waiting to use the restroom. The nurse who witnessed the event stated it was an intentional backhanded slap and that the residents had been arguing throughout the morning. The facility’s investigation substantiated resident-to-resident abuse. The resident’s progress notes for the period reviewed contained no notes regarding the observed incident. The facility policy stated residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to implement policies and procedures for reporting a reasonable suspicion of a crime and for reporting alleged abuse violations to the State Agency for three sampled residents. R1 had diagnoses including hemiplegia and hemiparesis, major depressive disorder, dementia, and anxiety disorder, and a quarterly MDS showed a BIMS score of 7 out of 15, indicating severe cognitive impairment. R23 had diagnoses including schizophrenia, Alzheimer's disease, dementia, and cognitive communication deficit, and a quarterly MDS showed a BIMS score of 3 out of 15, also indicating severe cognitive impairment. R8 had diagnoses including parkinsonism, schizoaffective disorder, bipolar disorder, anxiety disorder, history of traumatic brain injury, altered mental status, and schizophreniform disorder; a quarterly MDS showed a BIMS score of 15 out of 15 and indicated he was cognitively intact. For the allegation involving R1 and R8, a staff member witnessed verbal threats by R8 toward R1 on 10/18/25 at 3:21 PM, but the State Agency received the report on 10/19/25 at 4:04 PM. CNA 1 stated she reported the incident immediately to LPN 5, while LPN 5 stated she was told about the incident and did not remember who she reported it to. The LPN unit manager stated the CNA reported the incident to her and that she notified the DON when she was informed, while the DON stated the required reporting time frame was 2 hours but that she reported it as soon as she found out about it. For the allegation involving R23 and R8, a staff member witnessed R8 intentionally hit R23 on the arm on 11/26/25 at 9:27 AM, but the State Agency received the report at 1:52 PM. LPN 1 stated he informed the DON immediately, and the DON again stated the required reporting time frame was 2 hours but that she reported it as soon as she found out about it. The facility policy stated the initial report of abuse or an incident resulting in serious injury was to be faxed or emailed immediately but no more than 2 hours after the event.
Failure to Address Abuse Victimization in Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents following victimization of abuse. R1 was admitted with diagnoses including hemiplegia and hemiparesis, major depressive disorder, dementia, and anxiety disorder, and had a quarterly MDS BIMS score of 7 out of 15, indicating severe cognitive impairment. Facility investigative documentation showed that a staff member witnessed another resident threaten to slap R1 and kill him and his family. R1's care plan did not address victimization of abuse or the potential for psychosocial harm. R23 was admitted with diagnoses including schizophrenia, Alzheimer's disease, dementia, and cognitive communication deficit, and had a quarterly MDS BIMS score of 3 out of 15, also indicating severe cognitive impairment. R23's care plan likewise did not address victimization of abuse or the potential for psychosocial harm. During interview, the DON confirmed that victimization of abuse was not addressed in either resident's care plan and stated that she would expect to see a care plan and interventions related to being at risk for further abuse.
Failure to Update Care Plan After Resident Aggression
Penalty
Summary
The facility failed to revise R8’s comprehensive care plan after documented aggressive behaviors toward other residents. R8 was admitted with diagnoses including parkinsonism, schizoaffective disorder, bipolar disorder, anxiety disorder, history of traumatic brain injury, altered mental status, and schizophreniform disorder. The quarterly MDS with an ARD of 08/20/25 showed a BIMS score of 15 out of 15, indicating R8 was cognitively intact and had not exhibited physical, verbal, or other behavioral symptoms toward others at that time. The care plan dated 09/16/25 identified a problem of verbal behavioral symptoms directed toward others, with interventions such as allowing distance in seating, assessing whether behavior endangered the resident or others, avoiding power struggles, maintaining a calm environment, and removing the resident from group activities when behavior was unacceptable. Facility investigative documentation showed a staff member witnessed R8 threaten to slap another resident and kill him and his family, and later witnessed R8 intentionally hit another resident on the arm. Review of the care plan showed no updated interventions to prevent R8 from abusing other residents after these incidents. During interview, the DON stated direct care nurses or nurse managers were responsible for day-to-day care plan updates and confirmed the care plan had not been revised after the incidents, adding that current interventions should have been reflected on the care plan. The facility policy stated care plans are revised as changes in the resident’s condition dictates.
Failure to Attempt Assistive Device for Contracted Wrist
Penalty
Summary
The facility failed to ensure assistive devices and treatment were attempted for a resident with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. The resident’s MDS showed impaired ROM of the upper extremity and no specialized rehabilitation services. The care plan identified pain/discomfort related to impaired mobility and contractures, with interventions including pain medication and repositioning. OT documentation from years earlier showed passive stretching, hand hygiene with the right hand opened, and a trial of a temporary splint, with the resident later refusing therapy and being discharged from OT. The OT note stated that without OT the resident was at risk for further progression of contracture, but there were no documented recommendations afterward to prevent decline in ROM of the right wrist or any other device attempted. A later rehab physician order request approved OT for therapeutic activities and orthotic management and training, but the resident was only seen for wheelchair positioning and was discharged from OT. During observations, the resident was in a wheelchair in the common/dining area with a contracted right wrist and closed hand, and no splint or device was in place. The OTA confirmed the resident was not seen for orthotic management for the right wrist contracture and that there were no orders for a splint, brace, or other device. CNA staff were unaware of any device for the contracted wrist, and the DOR confirmed the last documentation regarding the right wrist contracture was from years earlier and that nothing had been attempted since then.
Failure to assess bed rail entrapment risk and obtain consent
Penalty
Summary
The facility failed to assess the entrapment risk of bedrails used for mobility assistance and failed to obtain consent for one of three residents reviewed for accident hazards, identified as R47. R47 was admitted with diagnoses including Alzheimer's disease and depression. Her quarterly MDS showed no upper or lower extremity impairments, dependence on staff for rolling side to side, and a BIMS score of 14 out of 15, indicating she was cognitively intact. Her care plan included impaired functional mobility with interventions for bed mobility assist handles on both sides of the bed, and a physician's order dated 03/25/25 stated that the resident uses bilateral grab bars for bed mobility. During observation, bilateral 1/8 side rails were present on R47's bed, and R47 stated she used them to help reposition herself in bed and demonstrated how she used them. The facility's side rail assessment dated 12/28/23 stated that bed rails were not indicated at that time. A progress note documented bilateral upper and lower body weakness and that the resident was able to grab bars and turn herself without injury. During interview, the DON stated that documentation of risks and benefits discussed and a consent form could not be located. The facility policy required attempts at alternatives, assessment of entrapment risk, review of risks and benefits with the resident and representative, and consent before bed rail use.
Failure to Prevent Administration of Allergen-Containing Medication
Penalty
Summary
A deficiency occurred when a resident with multiple documented allergies, including to sulfamethoxazole, was administered Bactrim DS, an antibiotic containing this allergen. The resident was admitted with a history of spinal stenosis, diabetes mellitus, hypertension, peripheral vascular disease, and other conditions. Upon admission, the resident's allergies were recorded in the facility's records, but a breakdown in communication and documentation led to the allergy not being properly updated in the pharmacy system. As a result, the pharmacy did not flag the order for Bactrim DS as contraindicated. The process failure began when an LPN received a telephone order for Bactrim DS after the resident exhibited symptoms of a urinary tract infection. The LPN bypassed a safety alert in the electronic medical record, incorrectly assuming that the provider was aware of the resident's allergy. The order was not properly verified with the provider, and the allergy was not communicated during the order entry process. The medication was administered from the emergency kit, and subsequent doses were given without further alerts, as the system did not continue to flag the allergy after the initial override. The resident experienced an allergic reaction, including flushing, redness, and rash, after receiving multiple doses of Bactrim DS. Staff interviews revealed confusion about the process for handling allergy alerts, the responsibilities for verifying allergies, and the communication between nursing staff, providers, and the pharmacy. The pharmacy's records were incomplete due to the allergy not being updated, and the facility's policies for medication orders and allergy documentation were not consistently followed, directly leading to the resident's exposure to a known allergen and resulting harm.
Failure to Administer Ordered Anticonvulsant Results in Resident Harm
Penalty
Summary
A deficiency occurred when a resident with a history of seizures and other complex medical conditions was re-admitted to the facility from an acute care hospital. Upon re-admission, the hospital's medication reconciliation report included new orders for Keppra, an anticonvulsant, and cephalexin, an antibiotic. However, these new medication orders were not entered into the facility's electronic medical record (EMR) and were not included in the resident's Medication Administration Report (MAR) from the time of re-admission through the date the resident was sent back to the hospital. Documentation by the receiving LPN did not indicate that new orders were verified with the physician, and the facility's process for double-checking and entering new orders was not followed as described in interviews with the ADON and DON. As a result of not receiving the prescribed anticonvulsant medication, the resident experienced seizure activity and required rehospitalization. The facility's policies required that new and readmission medication orders be clearly documented, verified, and entered into the EMR, but these steps were not completed for this resident. Interviews with staff revealed assumptions and gaps in communication regarding the entry and verification of new orders, contributing to the medication omission and subsequent harm to the resident.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to proper food safety and hygiene standards, as observed during a kitchen tour. The ice machine, located next to the handwashing station, was found to have dust and dirt around its interior, indicating inadequate cleaning. In the walk-in cooler, several food items, including romaine salad mix, slaw mix, cheese, and liquid eggs, were either expired or not properly labeled and dated after being removed from their original packaging. Similarly, in the walk-in freezer, waffles and pancakes were found unlabeled and undated after being removed from their original packaging. Additionally, during the kitchen tour, it was observed that two dietary cooks were not wearing beard guards while in the food preparation area, which is against the facility's hygiene protocols. Interviews with the acting Dietary Manager and the Administrator confirmed that the ice machine should be cleaned weekly, food items should be labeled and dated when opened, expired foods should be discarded, and staff with facial hair should wear beard guards. These deficiencies had the potential to adversely affect the 72 residents receiving an oral diet.
Privacy and Dignity Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure privacy during Activities of Daily Living (ADL) care for a resident with severe cognitive impairment and multiple diagnoses, including atrial fibrillation and rheumatoid arthritis. During an observation, it was noted that the privacy curtains were not fully drawn, and the window blinds were open, allowing visibility of the resident to anyone entering the room or from outside. This lack of privacy was confirmed by the Assistant Director of Nursing and a Certified Nursing Assistant (CNA) during the observation. The CNA later acknowledged the failure to provide full visual privacy during the provision of peri care. Additionally, the facility did not provide a dignity bag for a resident with a suprapubic catheter, as observed on multiple occasions. The catheter drainage bag was left uncovered and visible, contrary to the facility's policy. Interviews with a CNA, an LPN, and the Unit Manager confirmed that the drainage bag should have been covered with a dignity bag to maintain the resident's dignity. The staff acknowledged the oversight and confirmed the expectation that the dignity bag should always be in place.
Failure to Accommodate Resident Needs and Assess Placement
Penalty
Summary
The facility failed to provide a resident, identified as R18, with a chair that accommodated his height and ensured proper body alignment. R18, who had severe cognitive impairment and was non-ambulatory, was observed sitting in a Geri-chair that did not fit his height, causing him to slump and slide downward. The chair was not his assigned one, which was provided by Hospice and was left in the bathroom after being cleaned. Staff interviews confirmed that R18 was placed in the incorrect chair by the night shift and remained there throughout the day without attempts to correct the situation. Additionally, the facility did not assess two residents, R16 and R51, for appropriate placement on the Secured Unit. R16, with diagnoses including schizoaffective disorder and vascular dementia, was non-ambulatory and dependent on staff for care, with no documented behaviors or wandering tendencies. Despite this, R16 remained on the Secured Unit without reassessment. Similarly, R51, who had Alzheimer's Disease and was receiving hospice care, was non-ambulatory and dependent on staff, yet was placed in the Secured Unit without exhibiting wandering behaviors. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), revealed a lack of awareness regarding the residents' conditions and the criteria for placement in the Secured Unit. The DON confirmed that the unit was intended for residents with elopement risks, yet both R16 and R51 did not meet these criteria. The failure to assess and accommodate the individual needs of these residents resulted in inappropriate care and placement, highlighting deficiencies in the facility's processes for ensuring resident rights and safety.
Facility Fails to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, as observed in two of three halls. In bathroom 306 on Hall 3, a strong urine odor and missing floor tiles were noted during multiple observations. Additionally, in bathrooms 219 and 223 on Hall 2, raised toilet seats were found with dark brown substances, later identified as rust, coating their frames. During a tour with the Maintenance Director and the DON, both confirmed the presence of the urine odor, missing floor tiles, and rust on the toilet chairs. The Maintenance Director was unaware of these issues, stating that staff are required to submit a work order for repairs. The Housekeeping Supervisor also reported being unaware of the strong urine odor in room 306, despite staff having a log to address such issues.
Deficiencies in Care Planning for Abuse Prevention and Restorative Services
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, leading to deficiencies in addressing their specific needs. For one resident, who had a history of cerebral infarction, vascular dementia, epilepsy, intermittent explosive disorder, and schizoaffective bipolar disorder, the facility did not create a care plan to monitor and prevent future occurrences of abuse. This resident was involved in a resident-to-resident altercation, resulting in an injury, but no care plan was developed to address or prevent such incidents. Interviews with the Unit Manager and MDS Coordinator confirmed the absence of an abuse care plan, and the Director of Nursing acknowledged that such a plan should have been completed. Another resident, admitted with hemiplegia/hemiparesis following cerebral infarction and moderate cognitive impairment, required total assistance with daily activities and had precautions for contractures noted. However, the facility did not document a plan of care for Restorative Nursing Services. The Restorative Care/RN admitted to not completing an assessment for this resident to receive the necessary restorative services for mobility, indicating a lapse in care planning for the resident's specific needs.
Deficiencies in Resident Care and Equipment Provision
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve the functional abilities of three residents, leading to deficiencies in their care. Resident 18, who has severe cognitive impairment and multiple health conditions, was observed sitting in a Geri-chair that was not properly fitted, causing poor body alignment. The Director of Nursing confirmed that the resident was not in the assigned chair, which was left in the bathroom after being cleaned, and no attempt was made to place the resident in the correct chair. Resident 26, diagnosed with intellectual disabilities and severe cognitive impairment, was observed sitting in a wheelchair without a footrest, causing his feet to dangle. This oversight was confirmed by the Unit Nurse Supervisor, who acknowledged the risk of edema and foot drop due to the lack of a footrest. The Occupational Therapist noted that the wheelchair could be adjusted to prevent the resident's feet from dangling, but this was not done. Resident 40, with a history of hemiplegia and moderate cognitive impairment, was not receiving restorative care services for mobility or range of motion, despite precautions for contractures noted in the medical record. The Director of Nursing and the Restorative Care Nurse revealed that an assessment for restorative services was not completed due to a misunderstanding that hospice patients do not receive such services, which was later found to be incorrect.
Unsafe Storage of Personal Care Items in Shared Bathroom
Penalty
Summary
The facility failed to ensure that personal care items were safely stored in one of the shared bathrooms on the 300 Hall, specifically in room [ROOM NUMBER]. A can of personal shaving cream was observed on the bathroom sink, accessible to residents. The shaving cream's pamphlet listed warnings about its hazardous ingredients, including risks of explosion if heated, respiratory issues if inhaled, and nausea or vomiting if ingested. The Assistant Director of Nursing confirmed the presence of the shaving cream and acknowledged its potential hazard if ingested. An LPN also confirmed the shaving cream's presence and reported a high risk of accidental ingestion due to the low cognition and lack of safety awareness among wandering residents on the unit.
Failure to Use PPE During High-Contact Care
Penalty
Summary
The facility failed to ensure that staff used appropriate Personal Protective Equipment (PPE) for a resident under Enhanced Barrier Precautions (EBP). The facility's policy, dated June 2021, outlined the need for targeted gown and glove use during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms. However, during an observation, it was noted that a Certified Nursing Assistant (CNA) did not wear PPE while providing incontinent care to a resident with a wound, despite the presence of EBP signage on the resident's door. Additionally, there was no PPE readily available in the hallway or inside the resident's room, and the signage lacked specific instructions on donning and doffing PPE. Interviews with facility staff revealed a lack of awareness and focus on PPE use during high-contact care. The Assistant Director of Nursing (ADON) was more focused on privacy issues rather than PPE compliance, and the Administrator was unaware of the PPE non-compliance issue. The Infection Control Preventionist (IPC) confirmed that PPE was not kept at the resident rooms but at the front desk, and acknowledged the need for more specific instructions on PPE use. The CNA involved admitted to forgetting to wear PPE, prioritizing resident care over PPE compliance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Midway
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bryan County Hlth & Rehab Ctr | 10 mi | ★★★★★ | 12 | 0 |
| Abercorn Rehabilitation Center | 17.9 mi | ★★★★★ | 11 | 0 |
| Pruitthealth - Savannah | 18.2 mi | ★★★★★ | 1 | 0 |
| Coastal Manor | 21.1 mi | ★★★★★ | 0 | 0 |
| Oaks Health Ctr At The Marshes Of Skidaway Island | 21.5 mi | ★★★★★ | 7 | 0 |
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