Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Magnolia Manor during CMS and state inspections, most recent first.
A resident with hypothyroidism was admitted with a hospital discharge list that included levothyroxine 200 mcg daily, but the medication was not accurately reconciled or transcribed into the facility record and never appeared on the MAR. Admission and follow-up notes continued to reference Synthroid, yet the med reconciliation list did not include it, a pharmacy note referenced discontinuation without a located discontinue order, and the resident missed 66 doses. Later hospital records showed markedly elevated TSH and uncontrolled hypothyroidism, and staff interviews confirmed the admission medication review was not clearly completed.
A resident with multiple medical conditions and moderate cognitive impairment, who required assistance with dressing, was admitted with numerous new clothing items that were never inventoried or labeled as required by facility policy. There was no documentation of her belongings in the medical record, and her transfer paperwork showed no personal items were sent with her when she moved to another facility, while her family reported that about 20 new clothing items with tags were not returned. Surveyors observed 200–300 unlabeled clothing items, many brand new, in the laundry room, and the Housekeeping Manager stated she could not identify their owners without labels. The DON and Administrator confirmed that staff were expected to inventory belongings within 48 hours of admission but that no specific staff member was designated to complete this task, contrary to the written policy on resident personal belongings.
Surveyors identified failures in food storage and handling, including dented cans stored with non-dented cans, improperly sealed and undated frozen foods, and opened, undated dry goods. The Dietary Manager and Administrator confirmed that staff did not follow required labeling, dating, and storage procedures, and there was no policy for handling dented cans.
Two residents with significant range of motion (ROM) limitations and contractures had their MDS assessments inaccurately coded, failing to reflect their actual physical status. Despite medical records, care plans, and staff interviews confirming contractures and a below-the-knee amputation, the MDS assessments were marked as having no functional limitations, based on the rationale that these conditions were baseline for the residents. This discrepancy was acknowledged by facility staff, including the MDS nurse and DON, and could result in incomplete care planning.
A resident with chronic gout, emphysema, and anxiety was admitted without a complete baseline care plan within 48 hours, missing key elements such as fall risk precautions, dietary instructions, pain management, medication orders, and therapy services. The resident and representative were not provided with a summary of the care plan, and staff interviews confirmed the care plan was incomplete and not shared as required.
Two residents did not have complete care plans addressing all their medical and psychosocial needs. One resident's care plan omitted an antipsychotic medication being administered, while another's care plan failed to address contractures in the right hip and knee, despite these being present and documented elsewhere. Inaccurate MDS assessments and incomplete documentation contributed to these deficiencies, as confirmed by interviews with the DON, MDS nurse, and clinical leadership.
Two residents were found to have issues with their medication regimens: one received antipsychotic and anticonvulsant medications without appropriate diagnoses documented in the EMR, and another was prescribed an anticonvulsant for depression without proper side effect monitoring specific to the medication. The DON and ADON acknowledged gaps in documentation and monitoring during interviews.
A resident's Nursing Admission Assessment was found to be incomplete, lacking documentation on behaviors, fall history, elimination status, gait/balance, bowel and bladder status, and medications. The assessment did not accurately reflect the resident's status at admission, and the facility did not have a specific policy guiding the completion of these assessments.
A facility failed to immediately report and act on a sexual abuse allegation involving a resident with cognitive impairments. The accused CNA was not removed from duty until the following day, violating the facility's abuse policy and placing residents at risk. Staff interviews revealed confusion about reporting procedures.
The facility failed to report several allegations of abuse and misappropriation within required timeframes, affecting multiple residents. Incidents included a resident with cognitive impairments alleging sexual abuse by a CNA, a resident with severe cognitive impairments allegedly verbally abused by an LVN, and a resident reporting missing money. Additionally, two separate incidents of alleged sexual abuse involving residents were not reported within the required timeframe.
A resident with chronic pain and multiple health conditions experienced unmanaged severe pain due to the facility's failure to have prescribed pain medications available and inadequate communication with the physician. Despite orders for various pain medications, the facility did not notify the physician or take appropriate actions, resulting in the resident being transferred to the hospital for uncontrolled pain.
A resident with chronic pain and multiple diagnoses was admitted to a facility without necessary pain medications available. Despite experiencing severe pain, the facility failed to notify the physician, leading to the resident being transferred to the hospital for uncontrolled pain. Interviews revealed a lack of communication and protocol adherence among staff.
The facility failed to ensure nursing staff were competent in pain management and medication access, affecting two residents. One resident with serious health conditions did not receive a required pain assessment or timely pain medication, while another experienced confusion over medication availability. Staff interviews revealed a lack of awareness of procedures for urgent medication orders and physician notification.
The facility failed to manage controlled drugs and pain relief for two residents. One resident's hydrocodone was unaccounted for after discharge, while another experienced severe pain without adequate medication due to stock issues. Staff interviews revealed non-compliance with procedures for controlled substances and physician notifications.
The facility failed to maintain a gas stove in safe operating condition, with three rear burners and two ovens not igniting automatically. Staff had to use a lighter to ignite them, posing a risk of explosion and injury. The issue was not reported to the maintenance department.
The facility failed to ensure residents' rights to retain and use personal possessions, as four residents did not receive their personal clothes from the laundry over several days. This issue arose due to the laundry supervisor's absence and the relief staff not coming to work, leading to nursing staff having to retrieve clothes from the laundry.
The facility failed to ensure valid Do Not Resuscitate (DNR) orders for two residents, leading to the risk of unwanted lifesaving procedures. One resident had an incomplete DNR form, and another had a DNR form with a telephone consent instead of a signature, both rendering the DNRs invalid.
The facility failed to notify the physician when a resident's blood pressure and heart rate fell below prescribed parameters, leading to the withholding of the medication Coreg on multiple occasions. Despite the facility's policy requiring physician notification, the clinical record lacked documentation for these instances.
The facility failed to report an allegation of physical abuse within the required 2-hour timeframe to the State Agency. A resident reported being hit on the head by another resident, but the formal report was delayed due to the Executive Director/Abuse Prevention Coordinator being at church services. The incident was internally reported immediately, but the external reporting was not completed on time.
The facility failed to follow physician orders for a resident's oxygen therapy, administering 3 liters per minute instead of the prescribed 2 liters per minute. Both an LVN and the DON acknowledged the error, which could negatively affect the resident's lungs. The facility's Oxygen Administration policy was not adhered to, compromising the resident's well-being.
The facility failed to maintain daily nurse staffing data for at least 18 months. The secretary responsible for posting the data disposed of the previous day's report each day and was not instructed to retain them. The administrator confirmed that the postings should be maintained in a binder to ensure availability for review.
Failure to Reconcile and Administer Thyroid Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with hypothyroidism by not accurately reconciling and transcribing the hospital discharge medication on admission. The resident’s hospital discharge summary listed levothyroxine 200 mcg daily and indicated to continue Synthroid 200 mcg if within normal reference levels, but the facility’s physician orders and MARs for the admission period did not include any medication to treat hypothyroidism. The resident’s record also showed no documentation of a medication review at admission. The resident was admitted with diagnoses that included hypothyroidism, diabetes, acquired absence of the right leg below the knee, and major depressive disorder. Her care plan identified hypothyroidism, but there was no specific care plan related to that diagnosis. The admission note and subsequent follow-up notes documented hypothyroidism and stated to check TSH and continue Synthroid 200 mcg daily, yet the medication reconciliation list did not include levothyroxine. The facility record also showed a pharmacy review note stating to ensure levothyroxine was discontinued on admission, but there was no discontinued order located in the electronic record. The resident’s MARs for April, May, and early June showed no administration of levothyroxine, resulting in 66 missed doses. The resident later reported that she had not received her thyroid medication for over two months. Hospital records from a later admission showed a TSH of 155.000 and documented uncontrolled hypothyroidism with low T4, and the resident stated she had asked a nurse whether she was receiving the medication and was told she was not. Interviews with facility staff showed the admitting nurse entered the discharge medications, the ADON did not review the admission medications because she was on vacation, the NP could not recall reviewing the medication list, the DON could not locate documentation that the medication list was reviewed, and the pharmacist stated the levothyroxine was not activated and that nursing staff needed to clarify the order.
Failure to Inventory and Label Resident Clothing and Personal Belongings
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure a resident’s right to retain and use personal possessions, including clothing, by not properly inventorying and labeling the resident’s belongings. A female resident with diagnoses including cerebral infarction, sepsis, major depressive disorder, and generalized anxiety was admitted with moderate cognitive impairment, evidenced by a BIMS score of 08, and required supervision or touching assistance for dressing. Her care plan documented a self-care deficit and the need for staff assistance with dressing, but there was no documentation in her medical record that her personal items were inventoried at admission or at any time during her stay. Record review showed no inventory of the resident’s belongings in her assessments or progress notes from 10/08/2025 to 10/13/2025, and her transfer form indicated that no personal belongings were sent with her when she was transferred to another facility out of state. The resident’s family member reported that approximately 20 brand new clothing items with tags had been purchased for her stay, and that these items were neither returned to the resident nor sent with her upon transfer. The facility’s own transfer documentation confirmed that no personal belongings accompanied the resident. During observations and staff interviews, surveyors found approximately 200–300 pieces of unlabeled resident clothing in the laundry room, including many brand new items with tags, which the Housekeeping Manager stated could not be matched to residents because they lacked names. The Housekeeping Manager reported that she relied on clothing being labeled to return items and that she found unlabeled clothing every day. The DON and Administrator both stated that staff were responsible for inventorying residents’ items at admission and completing the process within 48 hours, but acknowledged there was no designated person assigned to perform this task. The facility’s written policy required that all resident personal items be inventoried at admission by social services or another designated staff member and documented in the medical record, and that the facility exercise reasonable care to protect resident property from loss or theft, which was not followed in this case.
Improper Food Storage and Handling Practices Identified in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the storage, preparation, and handling of food items. During inspections, dented cans of food were found co-mingled with non-dented cans on storage racks, including cans of beans, fruit cocktail, and banana pudding. The Dietary Manager (DM) confirmed these cans were dented and acknowledged they should have been stored separately. The DM also stated that it was his responsibility to check for dented cans, but he had not done so before the surveyors arrived. Further observations revealed improper storage of frozen and dry food items. In the freezers, open and undated boxes containing breakfast sausage patties and garlic bread were found with their packaging ripped or not properly sealed, exposing the food to the elements. In the dry storage area, an opened and undated carton of thickened liquid and an opened, undated bag of strawberry gelatin mix were found. The DM was unable to determine when these items were opened and acknowledged that such practices could affect food quality and safety. Interviews with the DM and the Administrator confirmed that staff were expected to follow food storage and preparation policies, including labeling and dating all products. However, the DM admitted that staff had not paid attention to these requirements, and the Administrator noted there was no policy for storing dented cans. The facility's own policy and the FDA Food Code require proper labeling, dating, and separation of compromised food items, but these standards were not met during the survey.
Inaccurate MDS Coding of Range of Motion Limitations for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the range of motion (ROM) limitations for two residents. For one resident, the most recent quarterly MDS assessment did not capture the contracture of her left knee, despite her medical record, care plan, and staff interviews confirming a longstanding contracture and associated interventions such as positioning for comfort and prevention of further contracture. The resident herself reported an inability to straighten her left knee for years, and both the care plan and staff acknowledged the contracture and related care needs. However, the MDS was coded as having no functional limitations to her extremities, based on the MDS nurse's interpretation that the contracture was the resident's baseline normal. For the second resident, the significant change MDS assessment failed to document contractures and ROM limitations on her right side, including her right elbow, hip, and knee, as well as a right below-the-knee amputation (BKA). The resident's care plan addressed only the contracture of her right elbow and did not mention the hip and knee contractures. Observations and staff interviews confirmed the presence of these contractures and the BKA, with care interventions in place for positioning and protection. The MDS, however, was coded as having no impairment in ROM or functional limitation, again based on the MDS nurse's rationale that these conditions were the resident's baseline. Interviews with facility staff, including the former MDS nurse, DON, and Regional Director of Clinical Operations, confirmed that the MDS assessments did not accurately reflect the residents' actual ROM limitations. The staff acknowledged that the inaccurate coding could result in care plans that do not fully address the residents' needs. The facility did not have a specific MDS policy and relied on the RAI manual for assessment and coding instructions.
Incomplete Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a complete baseline care plan within 48 hours of admission for a newly admitted male resident with diagnoses including chronic gout, emphysema, and adjustment disorder with anxiety. The baseline care plan was missing several required elements, such as a precautionary plan for fall risk, dietary instructions for a No Added Salt diet, prescribed PRN pain medications, routine medications, physician treatment orders for moisture associated skin damage (MASD), and prescribed therapy services. Additionally, the resident and his representative were not provided with a summary of the baseline care plan as required. Record reviews showed that the resident had significant pain, requiring administration of tramadol, and was receiving allopurinol for gout. Interviews with the DON and Regional Director of Clinical Services confirmed that the baseline care plan was incomplete and that a copy had not been provided to the resident or his representative. The administrator acknowledged that the baseline care plan was not properly completed and that this was the responsibility of the DON. The facility's policy required a baseline care plan to be developed within 48 hours of admission, including all necessary instructions and a summary provided to the resident or representative, which was not done in this case.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans to address all identified needs for two residents. For one resident, who had diagnoses including anxiety disorder, major depressive disorder, and bipolar disorder, the care plan did not include an order for Risperidone, an antipsychotic medication that was being administered. The care plan listed other psychotropic medications but left the section for Risperidone blank, despite a physician's order for its use. The DON acknowledged that the omission was not noticed and stated that care plans are expected to be accurate to ensure all resident needs are addressed. For another resident with a history of cerebral infarction, hemiplegia, hemiparesis, and contracture of the right lower extremity, the care plan only addressed a contracture of the right elbow and did not include contractures of the right hip and knee. Observations confirmed the presence of contractures in the right hip and knee, and interviews with staff indicated that these were present upon admission but not reflected in the care plan. The MDS assessment for this resident was also found to be inaccurate regarding range of motion, which contributed to the incomplete care plan. Interviews with facility staff, including the former MDS nurse, DON, and Regional Director of Clinical Services, confirmed that the care plans were incomplete due to inaccurate assessments and documentation. The facility's policy requires individualized, comprehensive care plans based on thorough assessments, but this was not followed in these cases, resulting in the failure to address all medical, nursing, and psychosocial needs for the affected residents.
Failure to Ensure Drug Regimens Were Free from Unnecessary Medications and Lacked Proper Monitoring
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary medications for two residents. For one resident, there was no appropriate diagnosis entered for the orders of Risperidone (an antipsychotic) and Divalproex (an anticonvulsant), despite these medications being prescribed. The pharmacy consultant had flagged the Risperidone as unnecessary for anxiety and requested its discontinuation, but the medication remained ordered without the correct diagnosis documented in the electronic medical record. The Director of Nursing (DON) acknowledged that during a transition between electronic medical record systems, some diagnoses did not transfer over and had to be manually entered, resulting in missing or incorrect documentation for these medications. For another resident, the facility did not ensure appropriate monitoring for side effects of Oxcarbazepine, which was prescribed for depression. Although the pharmacy consultant requested side effect monitoring for this medication, the monitoring order in the record was for an antidepressant, not specifically for Oxcarbazepine. The Assistant Director of Nursing (ADON) confirmed that the medication was being used for depression and not as an anticonvulsant, but the side effect monitoring was not correctly aligned with the medication’s use. The DON stated that she expected correct diagnoses to be associated with medications and for proper side effect monitoring to be conducted, but this was not consistently done.
Incomplete Nursing Admission Assessment
Penalty
Summary
The facility failed to ensure that a resident's Nursing Admission Assessment was complete and accurately reflected the resident's status at the time of admission. Specifically, the assessment for a male resident with diagnoses including chronic gout, emphysema, and adjustment disorder with anxiety did not include information on behaviors, fall history, elimination status, gait/balance, bowel and bladder status, or a list of medications. The 5-day Minimum Data Set (MDS) was still in progress, and the clinical record lacked the required comprehensive assessment details as outlined in the MDS 3.0 Resident Assessment Instrument (RAI) Manual. During an interview, the Administrator confirmed that the assessment was incomplete and did not meet expectations for accuracy and thoroughness. The Administrator stated that the Director of Nursing (DON) was responsible for ensuring assessments were complete and that all staff had been trained and retrained on this process. The Admissions Nurse previously responsible for completing admission assessments was no longer employed due to performance issues, and a new employee had recently started. The facility did not have a specific policy for completing admission assessments accurately, relying instead on the assumption that the questions were self-explanatory.
Failure to Report and Act on Abuse Allegation
Penalty
Summary
The facility failed to implement its written abuse policy effectively, resulting in a delay in reporting an allegation of sexual abuse involving a resident. The incident involved a resident with a history of cognitive impairments and mental health disorders, who alleged that a CNA had sexually abused her. Despite the resident's refusal to have the CNA assist her, the allegation was not immediately reported to the Abuse Coordinator or the State Agency as required by the facility's policy. The deficiency was further compounded by the failure to remove the accused CNA from duty immediately after the allegation was made. The CNA continued to work with residents until the following day, when the allegation was finally reported to the appropriate authorities. This delay in action placed residents at risk of further abuse and violated the facility's protocol for handling such allegations. Interviews with staff revealed a lack of clarity and adherence to the reporting procedures, with some staff members unaware of the requirement to report directly to the Abuse Coordinator. The facility's policy clearly outlined the steps to be taken in the event of an abuse allegation, including immediate suspension of the accused staff member and prompt reporting to the relevant authorities, but these steps were not followed in this instance.
Failure to Timely Report Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to report several allegations of abuse and misappropriation within the required timeframes, affecting six residents. One incident involved a resident with a history of cognitive impairments and mental health disorders who alleged sexual abuse by a CNA. The allegation was not immediately reported to the Abuse Coordinator, and the CNA continued to work until the following day when the allegation was finally reported. The resident was later transferred to a behavioral hospital, and the facility's failure to report the incident promptly was identified as past non-compliance. Another incident involved a resident with severe cognitive impairments who was allegedly verbally abused by an LVN. The family reported the incident to a weekend supervisor, but it was not reported to the state agency until three days later. The investigation found the allegation unconfirmed, but the delay in reporting was a deficiency. Additionally, a resident reported missing money, but the allegation of misappropriation was not reported to the state agency within the required 24-hour timeframe, as the statement was misplaced. Further deficiencies included the failure to report two separate incidents of alleged sexual abuse involving residents within the two-hour timeframe. In one case, a resident reported inappropriate touching by another resident, and in another, a resident was observed with a hand placed inappropriately by another resident. Both incidents were reported to the state agency after the required timeframe, highlighting the facility's repeated failure to adhere to reporting protocols.
Failure in Pain Management for Resident with Severe Pain
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as Resident #7, who was experiencing severe pain. Resident #7, who had a history of end-stage renal disease, failed kidney transplant, liver transplant status, congestive heart failure, and chronic pain, was admitted to the facility and required pain management. Despite having orders for multiple pain medications, including oxycodone, acetaminophen, hydrocodone-acetaminophen, and a Fentanyl patch, the facility did not have the necessary medications available, resulting in the resident experiencing pain levels of 10 out of 10 and 8 out of 10 on different occasions. The facility's staff, including LVNs and the social worker, were aware of Resident #7's severe pain but failed to notify the attending physician or take appropriate actions to manage the pain effectively. The resident was transferred to the hospital for uncontrolled pain, where it was noted that the facility did not have the resident's Fentanyl patch or hydrocodone in stock. Upon returning to the facility, the resident continued to experience significant pain, yet the physician was not notified, and no additional pain management measures were taken. Interviews with facility staff, including the ADON, DON, and the Administrator, revealed that there was a lack of communication and adherence to protocols regarding pain management and physician notification. The facility's failure to ensure the availability of prescribed pain medications and to involve the physician in the decision-making process for pain management led to Resident #7 experiencing unmanaged pain, which could have been mitigated with proper adherence to professional standards and facility policies.
Failure to Notify Physician of Resident's Pain Management Needs
Penalty
Summary
The facility failed to notify the physician of a resident's need for pain medication upon admission and during subsequent episodes of severe pain. The resident, who was admitted with diagnoses including end-stage renal disease, congestive heart failure, and chronic pain, did not have his prescribed pain medications, such as oxycodone and fentanyl, available at the facility. Despite having orders for these medications, the facility did not inform the physician about the unavailability of the medications or the resident's severe pain episodes. On multiple occasions, the resident experienced unmanageable pain, with pain levels reported as high as 10 out of 10. The facility staff, including LVNs and the social worker, documented the resident's complaints of excruciating pain and labored breathing. However, there was no evidence that the physician was notified of these changes in the resident's condition. The resident was eventually transferred to the hospital for uncontrolled pain, where it was noted that the facility did not have the necessary pain medications in stock. Interviews with facility staff, including the LVN, ADON, DON, and the attending physician, revealed a lack of communication and failure to follow protocols for notifying the physician of significant changes in the resident's condition. The physician stated that he was not aware of the resident's need for pain management upon admission and would have taken appropriate actions if notified. The facility's failure to communicate effectively with the physician and ensure the availability of prescribed medications resulted in the resident not receiving appropriate medical treatment for pain management.
Deficiency in Staff Competency for Pain Management and Medication Access
Penalty
Summary
The facility failed to ensure that licensed nursing staff demonstrated the necessary competencies and skill sets in pain assessments, pain management, accessing the Controlled Medication Emergency Kit (CMEK), notifying physicians of changes in condition, and arranging urgently needed medication orders and deliveries from the pharmacy. This deficiency was observed in the care of two residents, Resident #7 and Resident #8, who were assessed for staff competency. The lack of competency in these areas could place residents at risk for prolonged and unnecessary pain and suffering, as well as a decreased quality of life. Resident #7, who was admitted with multiple serious health conditions including end-stage renal disease and congestive heart failure, did not receive a pain assessment interview as required. Despite having orders for several pain medications, there was a failure to administer pain medication on a specific date when the resident's pain level was documented as 8 out of 10. LVN II, responsible for Resident #7's care, was unaware of the need to document pain assessments and did not notify the physician or access the CMEK for pain management, citing a lack of knowledge about the procedures. Resident #8, who had diagnoses including dementia and arthritis, was also affected by the facility's failure to ensure staff competency. Although Resident #8 had orders for pain medication, there was confusion regarding the availability of Tylenol #3, and the resident was not informed of changes to her medication orders. The nursing staff, including CN/LVN NN and ADON, had to access the CMEK to provide the necessary pain relief. Interviews with staff revealed a lack of awareness and understanding of the procedures for ordering urgent medications and notifying physicians, which contributed to the deficiency in care provided to the residents.
Failure to Manage Controlled Drugs and Pain Relief
Penalty
Summary
The facility failed to establish a system for the receipt and disposition of controlled drugs, leading to unaccounted medications for two residents. Resident #6, who was admitted with diagnoses including malignant neoplasm of the pancreas and intestinal obstruction, had hydrocodone 7.5 mg/acetaminophen 325 mg brought in by family members. However, there was no physician order for this medication, and it was not listed in the medication administration records (MARs). Upon discharge, the hydrocodone was not sent with the resident, and the facility could not locate the narcotic count sheet or determine the medication's whereabouts, despite conducting a search and drug tests on staff. Resident #7, admitted with conditions such as end-stage renal disease and congestive heart failure, experienced severe pain levels of 8 and 10 out of 10. Despite having orders for various pain medications, including oxycodone and hydrocodone, the facility did not have these medications in stock. On one occasion, a hydrocodone tablet was administered from the emergency kit, but on another, the resident was not given any pain medication despite reporting excruciating pain. The facility failed to notify the physician about the unavailability of pain medications and the resident's severe pain, resulting in the resident being transferred to the hospital for uncontrolled pain. Interviews with staff revealed that the facility did not follow proper procedures for managing controlled substances and notifying physicians of changes in residents' conditions. The Administrator and Director of Nursing (DON) expected staff to adhere to policies regarding narcotic medications and to involve the physician in medical decision-making processes. The lack of adherence to these protocols contributed to the deficiencies observed in the management of controlled drugs and pain relief for the residents.
Failure to Maintain Safe Operating Condition of Kitchen Stove
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, specifically a gas stove. During observations and interviews, it was found that three rear burners and two ovens on the stove would not ignite when the knobs were turned. The Dietary Manager (DM) and Cook F confirmed that they had to use a lighter to ignite the burners and ovens when they failed to light automatically. The Maintenance Supervisor (MS) was not informed about these issues. The MS acknowledged that using a lighter to ignite the stove could cause an explosion and injuries to residents and staff. This failure to maintain the stove in safe operating condition was observed during initial and subsequent tours of the kitchen, and it was not reported to the maintenance department for repair.
Failure to Return Residents' Personal Clothes from Laundry
Penalty
Summary
The facility failed to ensure residents had the right to be treated with respect and dignity, including the right to retain and use personal possessions. This deficiency was observed in four residents who did not receive their personal clothes from the laundry over a period of several days. Resident #9, who has Alzheimer's Disease and moderately impaired cognition, reported missing all his pants and four shirts due to the laundry staff being on vacation. Resident #13, who is cognitively intact but requires extensive assistance with bathing and grooming, loudly complained about not receiving his clothes back from the laundry and still had missing shorts even after some clothes were returned. Resident #47, who has heart disease and senile degeneration of the brain, reported losing his clothes for the second time and could not find them. Resident #268, who has dementia and high blood pressure, was observed wandering and refusing to change clothes because his clothes were not returned from the laundry. His closet was found to be empty, and the LVN confirmed that the laundry staff had not been bringing clothes back due to the laundry supervisor's absence. The issue was further confirmed during an interview with the Administrator and the laundry supervisor. The Administrator was notified that nursing staff had to retrieve residents' clothes from the laundry because the laundry supervisor's relief had not been coming to work. The Administrator expected residents' personal clothes to be washed, dried, and returned by the next morning, but this did not happen while the laundry supervisor was on vacation. The Administrator was observed helping Resident #47 locate his clothes, indicating the facility's awareness of the issue but highlighting the failure to maintain residents' rights to their personal possessions during the laundry supervisor's absence.
Failure to Ensure Valid DNR Orders for Residents
Penalty
Summary
The facility failed to ensure the right to formulate an advance directive was provided for two residents. Resident #27, an elderly female with chronic obstructive pulmonary disease, hypertension, and congestive heart failure, had a Do Not Resuscitate (DNR) order that was incomplete. The physician's statement section of the Out of Hospital-Do Not Resuscitate (OOH-DNR) form was left blank, rendering the DNR invalid. During an interview, the Director of Nursing (DON) confirmed that the incomplete DNR would necessitate the initiation of lifesaving procedures, contrary to the resident's wishes. Resident #62, an elderly female with multiple serious health conditions including myocardial infarction, cerebral infarction, diabetes mellitus type 2, hypertension, respiratory failure, and a tracheostomy, also had an invalid DNR. The OOH-DNR form for Resident #62 included a telephone consent instead of a signature, which was not acceptable according to the facility's policy. The DON confirmed that this would also invalidate the DNR, requiring lifesaving procedures to be initiated against the resident's wishes. Interviews with the Medical Records (MR) staff and the newly appointed Social Worker (SW) revealed gaps in the process of verifying the completeness and accuracy of DNR forms. The facility's Advanced Directive policy, dated June 2016, did not provide guidance on ensuring the accuracy and completeness of OOH-DNR forms. This lack of proper documentation and verification could lead to the administration of unwanted lifesaving procedures for residents who had expressed their wishes to not be resuscitated.
Failure to Notify Physician of Withheld Medication
Penalty
Summary
The facility failed to provide services as outlined by the comprehensive care plan and did not meet professional standards of quality for consultation with the resident's physician when there was a significant change in the resident's condition. Specifically, the facility did not notify the physician when Resident #39's blood pressure and/or heart rate fell below prescribed parameters, leading to the withholding of the medication Coreg on multiple occasions in April 2024. The clinical record lacked documentation of physician notification for these instances, despite the facility's policy requiring such notification. Resident #39, who was admitted with a diagnosis of hypertension and was cognitively intact with a BIMS score of 14, had specific physician orders to hold Coreg if certain blood pressure or heart rate thresholds were not met. However, on nine occasions in April 2024, the medication was withheld without notifying the physician. Interviews with the UM, LVN, ADON, and DON confirmed the absence of documentation and acknowledged that the physician should have been notified. The facility's policy, revised in January 2024, mandates that nursing staff notify the physician of any significant changes in vital signs or medication administration, which was not followed in this case.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse within the required 2-hour timeframe to the State Agency. Resident #2 reported to facility staff that Resident #1 hit/slapped her in the head. The incident occurred on 3/29/2024 at 1:30 p.m., but the report to the State Agency was not made until 6:00 p.m., which is beyond the mandated 2-hour reporting window. This delay in reporting was acknowledged by the Executive Director/Abuse Prevention Coordinator, who cited being at church services as the reason for the delay. Resident #1, a 68-year-old with multiple diagnoses including unspecified intellectual disabilities, Down Syndrome, and major depressive disorder, was noted to have behavioral symptoms directed at others. On the day of the incident, Resident #1 admitted to hitting Resident #2 because she was obstructing the TV. The facility's ADON and NP were involved in assessing Resident #1, who was subsequently reminded that hitting others was inappropriate. New medication orders were issued for Resident #1 following the incident. Resident #2, who has Alzheimer's disease and anxiety disorder, reported the incident to the nurse, stating that she was hit on the head by Resident #1 while watching TV. A head-to-toe assessment revealed no visible injuries, but Resident #2 reported pain and was given Tylenol. The incident was immediately reported to the charge nurse, ADON, DON, and other relevant parties, but the formal report to the State Agency was delayed. Interviews with staff confirmed that the incident was reported internally as required, but the external reporting was not completed within the mandated timeframe.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not follow physician orders for a resident's oxygen therapy. The resident, who had diagnoses of congestive heart failure and chronic obstructive pulmonary disease, was ordered to receive oxygen at 2 liters per minute via nasal cannula. However, observations on multiple occasions revealed that the resident's oxygen was set at 3 liters per minute instead of the prescribed 2 liters per minute. During interviews, both an LVN and the DON acknowledged that the resident did not receive the correct dose of oxygen as ordered. The LVN and DON both indicated that the resident's lungs could be negatively affected by this discrepancy. The facility's Oxygen Administration policy, which was revised in October 2010, outlines the procedure for safe oxygen administration, including verifying physician orders and reviewing the resident's care plan. Despite these guidelines, the facility failed to administer the oxygen as prescribed, potentially compromising the resident's well-being.
Failure to Maintain Daily Nurse Staffing Data
Penalty
Summary
The facility failed to maintain the daily nurse staffing data for at least 18 months, as required. During an interview, the secretary responsible for printing and posting the daily nurse staffing data sheet stated that she disposed of the previous day's report each day and was not instructed to retain them. The administrator confirmed that the staffing postings should be maintained in a binder after each day to ensure availability for viewing or review. This deficiency was identified during a review of the staff posting dated 04/23/24.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 148 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Groves
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Grove Nursing Home | 1.6 mi | ★★★★★ | 0 | 0 |
| Sabine Heights Nursing And Rehabilitation Center | 2.4 mi | ★★★★★ | 15 | 0 |
| Port Arthur Nursing And Rehabilitation Center | 3.6 mi | ★★★★★ | 5 | 0 |
| Bonne Vie | 4 mi | ★★★★★ | 7 | 0 |
| Oakwood Manor Nursing Home | 13.3 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.