Magnolia Creek Nursing: Head Injury Ignored in Memory Care - TN
That was the Director of Nursing's position when federal inspectors arrived at Magnolia Creek Nursing and Rehabilitation this past August. The hematoma, she told them, was not caused by an injury or a fall. It was a mosquito bite. She had no concerns about the assessment or the care her staff had provided.
Then inspectors asked whether an unexplained injury to a resident's head required an investigation.
The Director of Nursing put her head down for a minute. Then she got up from the table and left the room.
The facility had not started an investigation into what happened to Resident #1. Not after the overnight aide noticed the lump. Not after nursing staff assessed him. Not after his family requested he be sent to the hospital. The investigation began only after Adult Protective Services contacted the facility and told them APS was already looking into it.
Resident #1 lived on the Memory Care Unit at Magnolia Creek. He could get out of bed on his own, even with the bed in its lowest position, and he wandered around the unit at night. The overnight certified nursing assistant, identified in the inspection report as CNA A, checked on him during her shift, but she was not monitoring him continuously. She had 15 to 16 other residents on the unit to look after.
At some point during that night, Resident #1 developed a hematoma on his head. CNA A told inspectors she had not seen it the night before. She did not report it as an injury of unknown origin. She did not flag it as something that might require investigation.
When inspectors asked CNA A whether she had received training on abuse that covered injuries of unknown origin, including something like an unexplained knot on a resident's head, she said she was not aware that a head injury could be a sign of abuse.
That gap in her training matters. On a memory care unit, residents cannot always say what happened to them. They cannot always say whether they fell, whether they hit something, whether someone hurt them. An unexplained injury on a nonverbal or cognitively impaired resident is, by definition, an injury whose cause is unknown. That is precisely the kind of harm that requires a paper trail, a formal inquiry, witness statements, and a determination of what occurred.
CNA A was not asked to provide a written statement about the incident until the date of the complaint survey itself, weeks after the fact. A second staff member, identified as Staff B, confirmed the same thing during the inspection: she too had been asked to write a statement only then, only because inspectors had arrived.
The Staff Development Coordinator was in the building the day Resident #1 was sent to the hospital at his family's request. She told the Director of Nursing about it. The Director of Nursing said she had no concerns. No investigation was opened. No one interviewed the overnight staff in any formal capacity. No one documented what, if anything, they had observed.
The administrator, when inspectors spoke with him separately, acknowledged the gap plainly. When a resident has an injury that cannot be explained, he told them, the facility would be required to investigate. He did not dispute that. He did not offer an alternative reading of events.
What the inspection record shows is a facility where the person responsible for nursing care concluded that an unexplained head wound on a dementia patient was a mosquito bite and moved on, where the aide who worked the floor that night had never been taught that such an injury could indicate abuse, and where the formal investigation began not from within but only after an outside agency forced the question.
A hematoma is bleeding beneath the skin, typically caused by blunt force, a fall, or impact with a surface. On a wandering resident who moves around an unsupervised unit at night, the possibilities are numerous and none of them are a mosquito bite. Mosquito bites do not cause hematomas.
The Director of Nursing's explanation was not a medical assessment. It was a way of closing a question that should have stayed open.
Inspectors cited the facility under a deficiency tag cross-referenced to F684, which covers the standard requiring facilities to provide necessary care and services to maintain residents at their highest practicable level of well-being. The inspection was a complaint survey, meaning someone contacted regulators about what happened at Magnolia Creek before inspectors ever walked through the door.
The inspection report does not identify who filed the complaint. It does not say whether Resident #1's family was told the facility's working theory was a mosquito bite. It does not say what the hospital found when he arrived there at their request.
What it says is that a man who wandered a memory care unit at night, who could not be watched continuously by a single aide managing 15 or 16 other residents, developed an unexplained injury to his head, and that the people responsible for his safety did not treat it as something that required an answer.
The aide who worked his floor that night was not asked what she saw until the day the complaint survey began. She had not been trained to understand why it mattered.
The Director of Nursing, when pressed on whether the facility had an obligation to investigate, left the room.
Resident #1 went to the hospital because his family asked for it, not because the facility sent him.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Magnolia Creek Nursing and Rehabilitation from 2025-08-12 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 3, 2026 · Our methodology
MAGNOLIA CREEK NURSING AND REHABILITATION in COVINGTON, TN was cited for violations during a health inspection on August 12, 2025.
That was the Director of Nursing's position when federal inspectors arrived at Magnolia Creek Nursing and Rehabilitation this past August.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.