Magnolia Creek Nursing: False Medical Records - TN
The resident had a hematoma on his forehead.
RN C told inspectors at Magnolia Creek Nursing and Rehabilitation that Resident #1 "did not respond verbally, open his eyes or grasp her hands during the neuro assessments" on May 25. When asked how she could document these assessments as normal, she said "on the Memory Care Unit it was impossible to have a normal neuro check assessment" but confirmed she had marked them normal anyway.
The resident's condition deteriorated enough that his wife demanded he be transferred to a hospital that day.
RN C told inspectors she concluded the unresponsive resident "did not want to be bothered and she didn't find that unusual." She said he was "asymptomatic except for sleeping a lot during the day, which was not unusual for him."
But sleeping through neurological testing is not the same as sleeping during the day.
The Director of Nursing told inspectors that neuro checks "would be documented as abnormal findings" if "the patient/resident does not wake up during the assessment and the patient/resident was unable to complete the assessment."
RN C also failed to complete an event note about the hematoma on the resident's forehead, despite facility policy requiring documentation when staff cannot explain bruising or injuries.
The false documentation extended beyond the neurological assessments. RN C recorded on the transfer form that she had notified the nurse practitioner and obtained orders to send Resident #1 to the hospital. But when inspectors called the nurse practitioner on July 25, she said "the facility had not called her on 5/25/2025 to discuss Resident #1's change of condition or request an order to transfer the resident to the ER."
The Director of Nursing confirmed that "notification to the provider should not be documented unless the provider was notified."
Other staff revealed systemic problems with RN C's documentation practices. LPN T told inspectors during a telephone interview that she "had worked with RN C on occasion and had to help RN C with documenting in the electronic health record."
"[Named RN C] has lots of trouble on the computer," LPN T said. "She forgets how to get in and how to complete documentation."
More troubling, LPN T admitted she had "documented assessments completed by RN C without performing the assessment herself." This means assessments recorded under one nurse's credentials were actually performed by another nurse entirely.
The resident left the facility before lunch was served on May 25. RN C said she "was about to give him his meds [medication] when his wife came in and demanded me to send him out." The resident had not eaten breakfast, though RN C said "that wasn't unusual for him."
The inspection found that few residents were affected by these documentation failures, but the level of harm was classified as minimal harm or potential for actual harm.
Federal nursing home regulations require accurate documentation of resident assessments and timely notification of physicians when residents experience changes in condition. The false records at Magnolia Creek violated both requirements.
The case illustrates how documentation failures can cascade. A nurse who struggles with computer systems documents normal assessments on an unresponsive resident. Another nurse covers by completing documentation she didn't perform. A nurse practitioner who was never called appears in records as having been notified and providing orders.
Meanwhile, a resident with a head injury and altered consciousness receives no event note about his condition and no actual physician notification about his deteriorating status.
The Director of Nursing acknowledged that blood pressure monitoring "is documented in the vital signs section of the record" and should be part of professional neurological assessment standards. She also confirmed that "nurses should not document an assessment on a resident using information provided to them by another nurse or staff member."
The inspection occurred in August following a complaint about the facility's practices. The documentation violations were classified under federal tag F0842, which covers requirements for accurate and complete medical records.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
MAGNOLIA CREEK NURSING AND REHABILITATION in COVINGTON, TN was cited for violations during a health inspection on August 12, 2025.
The resident had a hematoma on his forehead.
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.