Magnolia Ridge

F-F600

Level of Harm - Immediate A facility policy titled Behavioral Health Care and Services with a review date of 10/24/2022 documented: jeopardy to resident health or safety POLICY

Residents Affected - Few Each patient/resident . must receive and the Center must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a patient's whole emotional and mental well-being, .

PURPOSE

To provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care.

To provide comprehensive. collaborative, and integrated behavioral health care and services to patients utilizing an interdisciplinary care approach.

PRACTICE STANDARDS .

1.2 Ensuring that direct care staff interact and communicate in a manner that promotes mental and psychosocial well being; .

1.4 Providing an environment and atmosphere that is conducive to mental and psychosocial well being; .

1.) RI #60 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] and had diagnoses to include: Alzheimer's Disease, Dementia with Behavioral Disturbance, Schizoaffective Disorder, Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder.

RI #60's annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/06/2023 documented a Brief Interview for Mental Status (BIMS) score of 12 of 15 indicating moderate cognitive impairment.

RI #60's care plan with a focus area of . exhibits verbal behaviors related to: History of verbal outbursts directed toward others. history of cursing staff and other residents. had an initiated date of 06/26/2018 and a revision date of 03/09/2022 and included interventions initiated on 06/26/2018 that guided all staff to . Remove resident/patient from environment, if needed. Gently guide the resident from the environment while speaking in a calm, reassuring voice.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 70 015133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015133 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Ridge 420 Dean Drive Gardendale, AL 35071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 RI #60's progress notes contained an entry dated 07/25/2023 at 9:25 AM signed by Licensed Practical Nurse (LPN) #27 as follows: . Called to smoke porch . it was alleged . (RI #60) had thrown (an) ash tray at a staff Level of Harm - Immediate member and it hit (RI #287) on the right side of (his/her)head and ear . (he/she) continue to curse at staff and jeopardy to resident health or was place on one on one and was in (his/her) room. (RI #60) came out of the room again was cursing out safety loud at unseen people, the DON tried to assist (RI #60) back to (his/her) room with the assisted cna, (RI #60) left the room again and the cna was following (him/her) at this time (he/she) was uneasy to redirect, the DON Residents Affected - Few was trying to (assist) (RI #60) back to (his/her) room, . assisted to the shower by the cna then (he/she) (cursed) her out and told her to get out and don't come back .

On 03/11/2025 at 3:51 PM LPN #27 was asked about RI #60's behavior. LPN #27 said, RI #60 would curse at staff and called people names. LPN #27 said, at the time of the incident staff reported that RI #60 threw an ashtray at CNA #41, but they discovered that CNA #41 was the one that threw the ashtray first. LPN #27 said, RI #60 did talk to people not present and might have been talking to the voices in his/her head. LPN #27 said, if RI #60 was talking to the staff member on the porch and calling her names, she should have brought RI #60 inside. LPN #27 said, she triggered him/her. LPN #27 said, CNA #41 had worked with RI #60

before and knew how to deal with RI #60's behaviors, she was a seasoned CNA and knew how to deal with aggressive residents. LPN #27 said, CNA #41 was familiar with RI #60's behaviors and knew how to approach RI #60. LPN #27 said, CNA #41 throwing the ashtray at RI #60 was mental abuse and she triggered RI #60's behavior, and it would have made RI #60 feel upset and angry.

On 03/18/2025 at 10:15 AM an interview was held with CNA #40. CNA #40 said someone in the situation of being confronted by a caregiver who had thrown an ashtray would cause fear and most likely increase agitation. CNA #40 said RI #60 was known to exhibit behaviors, including cursing at staff. CNA #40 said, everyone knew to ignore those behaviors. CNA #40 said, the protocol was to walk away, ignore the behavior, and report it to the nurse.

On 03/05/2025 at 3:45 PM the Nurse Educator/Registered Nurse (RN) #18 was asked about the incident on 07/25/2023 with RI #60. RN #18 said, the staff should have walked away if they were getting upset and certainly should not have acted aggressive back toward the resident and thrown anything. RN #18 said, it was not an appropriate way to respond. RN #18 said, the harm was potential for physical injury to the resident or anyone around. RN #18 said the staff was aggravating the situation and made it worse by escalating the behavior and overall situation. RN #18 said, it would frighten the resident and make them more upset if they were already agitated. RN #18 said, an employee who was feeling frustrated with a resident should tell their supervisor they are feeling burned out and ask for a reassignment.

On 03/17/2025, at 4:15 PM, an interview was held with the Administrator (ADM). During the interview, the ADM was questioned about the incident involving RI #60 and CNA #41. The ADM indicated that the report was substantiated as mistreatment and CNA #41 intended to strike RI #60 by throwing an ashtray. The ADM said, it was an inappropriate response to the resident's behavior and if staff witnessed another staff member throw an ashtray at a resident they should act to protect the resident at all times and report the incident immediately.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 70 015133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015133 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Ridge 420 Dean Drive Gardendale, AL 35071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 On 03/18/2025 at 10:49 AM an interview with the Former Administrator (FADM) was conducted. During the interview, the FADM was questioned about what occurred prior to the incident, the FADM said, from what Level of Harm - Immediate she recalled RI #60 had been cursing CNA #41 who became upset and reacted by throwing the ashtray. jeopardy to resident health or When asked how staff should respond in a situation when a resident was exhibiting aggressive behavior, the safety FADM said, staff should report the aggressive behavior to the unit manager. The FADM said, staff failed to report to the unit manager. The FADM said, staff failed to report to the unit manager. The FADM said Residents Affected - Few someone could get hurt when staff became upset and responded by throwing an ashtray at a resident.

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The facility took immediate action to correct the noncompliance including:

07/25/2023, immediately brought into facility and placed on 1:1 with supervisor until sent out for psych evaluation

07/25/2023 - Body audits completed on both residents

07/25/2023 - Report made to ADPH

07/25/2023 - Police report filed with police department

07/25/2023 - Investigation initiated

07/25/2023 - Care Plans updated

07/26/2023 2nd report to ADPH

07/26/2023 - RI #60 seen by provider - medications adjusted for agitation

07/26/2023 - RI #287 assessed by provider - noted as stable

07/27/2023- CNA #41 was suspended

07/29/2023- CNA #39 was suspended

07/30/2023 - Interview: residents to rule out abuse and with staff members to ensure no unreported abuse

07/31/2023 - RI #60 seen by IBH provider - no behaviors noted; continues on IBH monthly

08/01/2023 - 100 percent of body audits completed - no concerns noted

08/01/2023-CNA #40 was suspended and terminated

08/02/2023- CNA #41 and #39 were terminated

08/08/2023- All staff educated on Behavior Management Education.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 70 015133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015133 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Ridge 420 Dean Drive Gardendale, AL 35071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 08/15/2023 - Monitoring behaviors and abuse through QAPI process

Level of Harm - Immediate 08/21/2023 - All staff educated on abuse and reporting abuse - completed by local ombudsman jeopardy to resident health or safety *********************************************************

Residents Affected - Few 2) RI #487 was admitted to the facility on [DATE REDACTED] with a diagnosis to include Vascular Dementia with Behavioral Disturbance, Mood Disorder Due to Known Physiological Disorder with Depressive Features, Adjustment Disorder with Depressed Mood.

A review of RI #487's Annual MDS with an ARD of 3/30/2023 documented a score of 14 of 15 on the BIMS which indicated RI #487 was cognitively intact. Section E0200 Behavioral Symptoms- Presence and Frequency was coded 2 for Verbal behaviors symptoms directed towards others (e.g. threatening others, screaming at others, cursing at others. Section D0100 Resident Mood Interview documented feeling down, depressed or hopeless 7 out of 11 days in the past two weeks of this assessment period.

A review of RI #487's Comprehensive Behavior Care Plans included a Focus of . (RI #487) exhibits or has

the potential to exhibit verbal behaviors related to cognitive loss/Dementia. (RI #487) as a history of verbal outburst. (He/She) is easily frustrated. (He/She) gets agitated, yells out, and curses because (he/she) wants to go home . Date Initiated: 07/12/2019 . Revision on: 10/04/2022 . Interventions . Social Services visits to provide support as needed, and/or as requested .

On 05/24/2023 at 10:52 AM the State Agency received a FRI alleging verbal abuse involving RI #487, RI #488, and a Dietary Aide (DA) #49 occurred when it was reported that DA #49 told both these residents he would whip their ass.

On 05/24/2023 a hand written document from Dietary Manager Assistant (DMA) documented, On this day (05/24/23) RI #487 came to me about not getting a grill cheese sandwich. I turns (RI 487) curse me calling me the (B) work. I (DMA) said you don't have to say all of that . (RI # 487) said yes (B) cause you can't read I (DMA) just fixed the toast and gave it to him/her ( RI #487) and went on my way .

A review of RI #487's behavior monitoring document revealed RI #487 exhibited behaviors nine out of 31 days in May 2023.

Further review of RI #487's Comprehensive Care Plan including behavioral care plans indicated no updates were made after the incident on 05/24/2023.

On 07/01/2023 at 10:05 AM, the State Agency received a Facility Reported Incident (FRI) that documented . Roommates (RI #487) and (RI #41) had an argument and (RI #487) bent (RI #41)'s finger Was there serious bodily injury? Yes . The facility immediately separated the residents, assessed for injuries, made notifications, and initiated an investigation.

A review of a hospital record date 07/1/2023 of RI #41 documented, . Reason for Admission: ASSAULT . A

review of a hospital X- Ray record of RI #41's Left hand documented, Significant Findings . Impression: Acute fracture of the ring finger .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 70 015133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015133 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Ridge 420 Dean Drive Gardendale, AL 35071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 A review of the facility's final summary dated 07/03/2023 documented . Complaint: (RI #487) became angry because (he/she) said (RI #41) yelled at (him/her) for turning on a TV and waking (him/her) up (RI #487) Level of Harm - Immediate walked over to (RI #41's) side of the room, where (RI #41) was in the bed, and hit (him/her) on the fist with jeopardy to resident health or (his/her) fist and twisted (RI #41's) left hand . The document stated the incident was not witnessed; however, safety staff heard an argument in the room prior to the incident.

Residents Affected - Few A review of the Integrated Behavioral Health (IBH) documentation indicated that Resident RI #487 was seen

on 03/06/2023, for a follow-up concerning agitation and depression. The records indicated that RI #487 exhibited irritability and was uncooperative with staff.

On 04/24/2023, RI #487 was again seen by IBH for a follow-up regarding the same issues of agitation and depression. The resident continued to display signs of agitation, used excessive profanity, and remained uncooperative with the staff.

On 05/11/2023, IBH conducted another follow-up for RI #487 concerning agitation and depression. During

this visit, RI #487 expressed frustration with his/her stay at the facility, used profanity, and reported experiencing poor sleep due to noise disturbances from his/her roommate.

On 03/06/2025 at 11:55AM the Social Services Assistant (SSA) #19. The SSA said RI #487 had behaviors that included verbal and physical aggression. The SSA said RI #487's became physically aggressive when he/she got to a point of anger. The SSA said RI #487 exhibited verbal aggression almost daily that included cursing, and he/she had an angry personality in general. When asked what would provoke RI #487, the SSA said it would have to be a situation that got him/her fired up and start to curse; he/she was easily angered.

The SSA said interventions included for staff would try to redirect him/her and he/she was a smoker so staff would try to take him to smoke. The SSA said staff should redirect, calm, and remove from RI #487 the situation. The SSA said she vaguely remembered RI #487's behavioral incident on 05/24/2023 when RI #487 went into the kitchen, asked for a grilled cheese, and got into an argument with staff. The SSA said the incident should have been documented in RI #487's care plan and nurses' notes, but she did not see it documented in the nursing notes or the care plan. The SSA did not see any specific interventions following

the incident in May 2023. The SSA said it was important to document incidents so staff would know how to handle his/her care and what may trigger him/her. The SSA said knowing how to handle resident's care and potential triggers was important so staff could avoid potential future situations that may impact a resident.

The documentation would also support the need to send the resident for inpatient services. The SSA said RI #487's care plan was not updated following the 05/24/2023 incident, but it should have been, and she did not know why it was not. The SSA said had the incident on 05/24/2023 been documented appropriately it could have possibly prevented the incident on 07/01/2023. The SSA said not communicating or documenting behaviors could lead to other behaviors and aggression that may impact residents. The SSA added, when new staff came in they need to be aware of the resident behaviors for protection of all.

On 03/14/2025 at 11:53 AM an interview was conducted with the Social Worker (SW) #17. The SW said RI #487 had care plans for verbal and physical behaviors. The SW said she was not aware of RI #487 being involved in the incident on 05/24/2023 and was only aware of the incident that occurred on 07/01/2023. The SW said she was not aware of any prior altercations between RI #487 and RI #41. The SW said the unit managers should let her know if there were any concerns. The SW said if she had been made aware and the facility was unable to come up with a resolution then a room change would be initiated. The SW said a room change was not offered until after the 07/01/2023 incident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 70 015133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015133 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Ridge 420 Dean Drive Gardendale, AL 35071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 *****************************************

Level of Harm - Immediate The facility took immediate action to correct the noncompliance including: jeopardy to resident health or safety 07/01/2023- RI #487 immediately placed on 1:1 Observation

Residents Affected - Few 07/01/2023 - RI #487 sent out to Hospital for Psychiatric Evaluation

07/01/2023 - X-Ray of RI #41's finger obtained

07/01/2023 - Body Audits to both residents

07/01/2023 through 07/04/2023 - Interviews with Staff and Residents

07/03/2023 - Interview with RI #41

07/04/2023 - Interview with RI #487

06/24/2023 - Review Care Plans for both Residents

07/15/2023 - QAPI

08/15/2023 - Behavior Antipsychotic Review

07/04/2023 - Room change upon RI #487's return from the hospital 315A

06/05/2023, 06/23/2023, 07/01/2023, and 7/31/2023 RI #487 was seen by IBH Provider

08/15/2023 - Monitoring behaviors and abuse through QAPI process

08/21/2023 - All staff educated on abuse and reporting abuse - completed by local ombudsman

May 2023 until 09/26/2023 RI #487 remained on Behavior Monitoring until discharge 09/26/2023

RI #487 continued being followed by psychiatric services until discharged on [DATE REDACTED].

09/26/2023 - RI #487 discharged home. It was recommended on discharge that resident continue IBH services.

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After review of documentation supporting the above corrective actions, including the facility's investigation file, in-service/education records, QAPI documentation, and staff interviews, the survey team verified the facility implemented corrective actions including ongoing monitoring from May 2023 to 09/26/2023, and past non-compliance was cited.

29671

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 70 015133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015133 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Ridge 420 Dean Drive Gardendale, AL 35071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 3.) On 09/13/2024 the State Agency received a FRI alleging physical abuse occurred the day before on 09/12/2024 at 10:45 PM when RI #339 stabbed RI #3 in the left hand with an ink pen causing a gash, the Level of Harm - Immediate residents were separated, and Emergency Medical Services (EMS) were requested and the Police were jeopardy to resident health or notified. safety RI #3 was readmitted to the facility on [DATE REDACTED] and had diagnoses to include: Vascular Dementia. Residents Affected - Few RI #3's admission MDS assessment with an ARD of 07/19/2024 documented long and short term memory problems and moderately impaired cognition.

RI #339 was admitted to the facility on [DATE REDACTED] with diagnoses to include Depression and Post-Traumatic Stress Disorder.

RI #339's quarterly MDS assessment with an ARD of 07/17/2024 documented a BIMS score of 15 out of 15 indicating intact cognition.

Further review of RI #339's medical record revealed comprehensive care plans and progress notes describing some of RI #339's behaviors leading up to the incident on 09/12/2024.

RI #339 had a care plan initiated 08/15/2024 to address the focus area of exhibiting verbal behaviors, history of verbal outbursts directed at others, use of abusive language, pattern of challenging/confrontational verbal behavior.

RI #339's care plans did not include any focus areas, interventions, approaches, or guidance to staff to address physical aggression, throwing things, night terrors, flashbacks, or sleeplessness; and did not address the level of supervision required to ensure RI #339's roommate and other residents were safe in the facility.

RI #339's progress notes included documented behaviors as follows:

07/02/2024 Resident has had increased yelling and cursing staff members. Refusing medications at times, refusing . care .

08/19/2024 Resident threw (his/her) phone at CNA . Gave the unit manager the middle finger and said f@@k you.

09/03/2024 Hell no I'm not taking a shower.

09/12/2024 at 11:31 AM .up in (wheelchair) .stated, (roommate) took my remote. cursing this writer and another resident in the hallway. Attempts to redirect (RI #339) are unsuccessful.

09/12/2024 at 9:09 PM Resident refused to go to bed after telling the CNA (he/she) was ready to go to bed. Cursed and yelled at the CNA and then went back outside.

The behavior documented at 9:09 PM occurred less than two hours prior to RI #3 being stabbed with the pen.

RI #339's IBH note dated 08/23/2024 documented:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 70 015133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015133 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Ridge 420 Dean Drive Gardendale, AL 35071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Reason for Appointment

Level of Harm - Immediate 1. Initial encounter for psychiatric evaluation for medication management . jeopardy to resident health or safety Caregivers report that patient threw a phone across (his/her) room. frequent episodes of cursing at staff. patient stays awake late at night . Residents Affected - Few (RI #339) Endorses some irritability (related to) living in the facility. (He/she) states that (his/her) cellphone wasn't working, and (he/she) did throw it across (his/her) room. (He/she) states that (he/she) got in a fuss with some people this morning, just messing with me. Reports trouble staying asleep at night, . Endorses night terrors . flashbacks . terrors are through my lens shooting people.

Assessments

1. Post-traumatic stress disorder .

2. Depression .

RI #339's IBH report dated 09/06/2024 documented:

Reason for Appointment

1. (follow-up) for depression and PTSD .

Describes mood as irritable. Endorses irritability due to not sleeping well at night.

Endorses nightmares of past combat . no longer nightly. monitor for improvement in night terrors.

IBH reports recommended treatment should include non-pharmacological interventions and coping strategies, but the reports did not specify any examples or discussion of these with RI #339.

The facility investigative file contained a form titled, INVESTIGATION REPORT for RI #3 dated 09/14/2024 which documented on 09/12/2024 Licensed Practical Nurse (LPN) #38 called and reported to the Administrator (ADM) and Director of Nurses (DON) that RI #339 stabbed RI #3 in the left hand. A Conclusion to the report documented: . the facility completed an investigation and there is sufficient evidence to substantiate an allegation of physical abuse (Resident to Resident). (RI #3) transferred to the hospital on 9/12/24 for evaluation of (his/her) left hand. (RI #3) is monitored for any psychosocial changes. (RI #339) transferred to three different hospitals on 09/13/24. After the incident, the residents were separated as roommates. The facility staff was also reeducated on abuse reporting and reporting any roommate incompatibility.

On 03/02/2025 at 3:50 PM an interview was conducted with RI #3. RI #3 stated, RI #339 was his/her roommate and would yell out at times. RI #3 stated, on 09/12/2023 RI #339 stabbed his/her hand and he/she was sent to the hospital and required three stitches. RI #3 further stated that he/she tried to defend himself/herself from the roommate. RI #3 stated his/her hand was hurt and bleeding. RI #3 stated, at the time of the incident he was scared.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 70 015133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015133 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Ridge 420 Dean Drive Gardendale, AL 35071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 The facility investigative file contained a handwritten statement signed by RI #339 dated 09/12/2024 which documented: . (RI #3), my roommate said something about a phone charger while we were on the smoking Level of Harm - Immediate patio earlier today. I looked for my notepad and my remote control. They were missing. After we came from jeopardy to resident health or the smoking patio, I got (RI #3's) phone and charger out of the garbage can and threw both of them at safety (him/her). I accused (RI #3) of stealing my stuff. I told (him/her) I will kill (him/he) if (he/she) goes through my stuff. (RI #3) rolled (his/her) wheelchair towards me and I stabbed (him/her) in the hand. Residents Affected - Few

On 03/07/2025 at 9:33 AM Social Services Assistant (SSA) #19 said, she was aware that occasionally RI #3 and RI #339 would have a disagreement. SSA #19 said, RI #339 had diagnoses to include PTSD, Depression, and was seen by IBH/psychiatric on 08/23/2024 and 09/06/2024 because behaviors were getting worse, he/she was cursing more and refusing treatment.

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The facility took immediate action to correct the noncompliance including:

09/12/2024- Separated the residents

09/12/2024- One on One observation with RI #339; RI #339 sent to inpatient psych services for evaluation.

09/12/2024- RI #339 did not return to facility after this incident.

09/12/2024- Body Audit Completed

09/12/2024- Police Notified

09/12/2024- Sent RI #3 to ER for evaluation

09/12/2024-Investigation initiated/Reported to ADPH/Ombudsman

09/13/2024- Employees Training on Abuse Policy Education, Roommate Incompatibility, Early Identification of residents concerns. Roommate Incompatibility reviewed on 09/13/2024 conducted by IDT during Stand up. Roommate Incompatibility monitoring continued weekly during the Partner Round program.

09/17/2024 - Employee Training on Behavior Management

09/23/2024- ADHOC QAPI-Completed

10/04/2024-Town Hall Meeting with all Staff.

After review of documentation supporting the above corrective actions, including the facility's investigation file, in-service/education records, QAPI documentation, and staff interviews, the survey team verified the facility implemented corrective actions including ongoing monitoring from 09/12/2024 to 10/04/2024 and past non-compliance was cited.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 70 015133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015133 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Ridge 420 Dean Drive Gardendale, AL 35071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20304

Residents Affected - Many Based on observation, interview, the facility's policies for Menus and Portion Control, the facility's Fall/Winter Menu for Week 3, and the Portion Control Chart posted in the facility's kitchen; the facility failed to ensure the correct food portions were served to residents for Mandarin Orange Sections at Supper on 03/02/2025 and for Puree [NAME] Stew without Corn, Puree Bread, Puree Tomato Soup, Mashed Potatoes, Tossed Salad, and Shredded Lettuce Salad served at Lunch on 03/04/2025.

This had the potential to affect 132 of 132 residents receiving meals from the facility's kitchen.

Findings include:

The facility's policy for Menus, undated, included the following:

. Policy Statement

Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines.

Procedures .

5. A Registered Dietitian/Nutritionist (RDN) . reviews and approves the menus. The RDN . will adjust the individual meal plan . as appropriate.

6. Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal.

7. A menu substitution log will be maintained on file.

The facility's policy for PORTION CONTROL, undated, included the following:

Menus and recipes are built with specific portions to meet resident's needs.

Portions must be followed during all phases of food production and service. The following is the portion/scoop conversion for most items served.

Scoop Number (#)* Measure Weight in Fluid Ounces (fl oz)

2 . 1 cup (C) 8 fluid ounces .

6 . 2/3 C 6 fl oz

8 . 1/2 C 4 fl oz

10 . 3/8 C 3.2 fl oz

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 70 015133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015133 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Ridge 420 Dean Drive Gardendale, AL 35071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 12 . 1/3 C 2.6 fl oz

Level of Harm - Minimal harm or 16 . 1/4 C 2.0 fl oz . potential for actual harm * Scoop number is based on the number of portions/quart (portions per quart). Residents Affected - Many

The facility's Fall/Winter 2024-2025 Menu for Week 3 included the following for Sunday (Day 15) Dinner on 03/02/2025:

The Diet Guide Sheet identified one serving of Peach Cobbler with Whipped Topping or a #8 scoop of Puree Peach Cobbler or 1/2 cup of Sliced Peaches to be served for dessert, depending upon the diet type.

The Menu Substitution Log for 03/02/2025 identified Fruit to be substituted for Peach Cobbler.

On 03/02/2025 at 5:25 PM, the delivery of Dinner trays to residents on the East Hall was observed. Although

the menu listed Peach Cobbler with Whipped Topping for dessert, either Mandarin Orange Sections or Applesauce were being served instead. The Applesauce was served in 4-ounce commercial packages. The Mandarin Orange Sections were served in a clear plastic fluted dessert bowl, but the portion size in each bowl appeared to be 1/4 cup (2 ounces).

In an interview on 03/02/2025 at 5:30 PM, the Dietary Manager said the Mandarin Orange Sections had been added to the substitute list. The Dietary Manager measured the amount of Mandarin Orange Sections being served and found only two ounces of Mandarin Orange Slices in the dessert bowl. A 2-ounce spoodle was used to check the serving size and the Mandarin Orange Sections fit inside the spoodle without any overflow. The Dietary Manager said two ounces of Mandarin Orange Slices was not enough for a serving.

The facility's Diet Guide Sheet for the Fall/Winter 2024-2025 Menu for Week 3, Tuesday (Day 17) at Lunch

on 03/04/2025 indicated the following serving portions:

8 ounces of Puree [NAME] Stew without Corn,

a #8 scoop of Puree Bread,

a #6 scoop of Puree Tomato Soup,

1/2 cup of Mashed Potatoes,

one cup of Tossed Salad, and

one cup of Shredded Lettuce Salad.

On 03/04/2025 at 12:14 PM, trayline service for Lunch was observed. The Tossed Salad and Shredded Lettuce were being held on the trayline over ice. Each salad had a #8 scoop as the serving utensil.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 70 015133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015133 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Ridge 420 Dean Drive Gardendale, AL 35071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 On 03/04/2025 at 12:35 PM, the Dietary Manager was on the line serving Tossed Salad and Shredded Lettuce into 6-ounce insulated, plastic bowls. The Dietary Manager said an 8-ounce scoop was being used to Level of Harm - Minimal harm or serve each salad. The Dietary Manager then displayed the scoop's number 8 metal imprint. It was a #8 potential for actual harm scoop (1/2 cup or 4 ounces).

Residents Affected - Many On 03/04/2025 at 1:00 PM, the AM [NAME] was observed using a #8 Scoop (grey handle), which was not quite filled, to put Pureed [NAME] Stew without Corn atop Mashed Potatoes. The Mashed Potatoes were served with a #12 Scoop (green handle). The Puree Tomato Soup was served with a #10 Scoop (white handle). The Puree Bread was served with a #12 Scoop (green handle). The numbers on the scoops were verified with AM Cook.

On 03/04/2025 at 1:25 PM, a copy of the Portion Control Chart posted in the kitchen was requested.

On 03/04/2025 at 2:00 PM, the AM [NAME] was interviewed. The AM [NAME] was asked to identify the scoops used for specific Puree items during Lunch. The AM [NAME] said Pureed [NAME] Stew without Corn was served with an 8-ounce scoop, Pureed Tomato Soup was served with a 10 scoop, Puree Bread was served with a 12 scoop, and Mashed Potatoes with a 12 scoop. The AM [NAME] said she knew how much to serve by looking at the menu and the production sheet. The AM [NAME] was given a copy of the menu and asked how much Pureed [NAME] Stew without Corn should be served. The AM [NAME] looked at the Diet Guide Sheet for Tuesday (Day 17) Lunch on the Fall/Winter 2024-2025 Menu for Week 3 and said, One cup. Upon further questioning, it was revealed that the AM [NAME] believed the #8 scoop held 8 ounces, when it actually only held 4 ounces (1/2 cup). When asked for the amount of Mashed Potatoes to be served according to the menu, the AM [NAME] said, It should be one-half cup. The AM [NAME] was given a copy of

the Portion Control Chart that had been posted in the kitchen and asked how much a #12 scoop provided.

The AM [NAME] said, one-third cup. The AM [NAME] further said that is a little less than half a cup. When asked how this could affect the residents, the AM [NAME] said, They can lose weight.

On 03/05/2025 at 4:21 PM, the Dietary Manager was interviewed. The Dietary Manager said the proper serving size for a portion of Mandarin Orange Sections was 4 ounces. The Dietary Manager said serving food in amounts less than listed on the menu would affect the resident's diet and could cause weight loss.

On 03/05/2025 at 5:00 PM, the Registered Dietitian (RD) was interviewed. The RD said the proper serving size for a portion of Mandarin Orange Sections was one-half cup (4 ounces). The RD said serving food in amounts less than listed on the menu would result in not enough calories and nutrients. The RD further said

it could also cause weight loss.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 70 015133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015133 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Ridge 420 Dean Drive Gardendale, AL 35071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20304

Residents Affected - Many Based on observation, interview, the facility's policies for Food Storage: Cold Foods and Meal Distribution,

the facility's Labeling and Dating Inservice, and the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code; the facility failed to prevent possible cross-contamination by allowing meat to thaw on a shelf 3.5 inches from the floor, incompletely covered meal plates to be delivered on an open cart to residents throughout the facility on [DATE REDACTED] for Supper, and a damaged Handwashing Sink with a draining issue and no cold water to be used by staff. The facility further failed to ensure Use By dates were used for sandwiches prepared for residents' snacks.

This had the potential to affect 132 of 132 residents receiving meals from the facility's kitchen.

Findings include:

The facility's undated policy for Food Storage: Cold Foods, included the following:

. Policy Statement

All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code.

Procedures

1. All food items will be stored 6 inches above the floor .

The facility's policy for Meal Distribution, undated, included the following:

. Policy Statement

Meals are transported to the dining locations in a manner that . protects against contamination, .

Procedures .

3. All foods that are transported to dining areas that are not adjacent to the kitchen will be covered.

The facility's Labeling and Dating Inservice, undated, included the following:

. 'Use By' Dating Guidelines .

All Ready-to-Eat, Time/Temperature Control for Safety (TCS) foods that are to be held for more than 24 hours at a temperature of 40 F or less, will be labeled and dated with a 'prepared date' (Day 1) and a 'use by date' (Day 7).

The 2022 FDA Food Code included the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 70 015133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015133 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Ridge 420 Dean Drive Gardendale, AL 35071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 XXX,d+[DATE REDACTED].11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation.

Level of Harm - Minimal harm or (A) FOOD shall be protected from cross contamination . potential for actual harm ,d+[DATE REDACTED].11 Food Storage. Residents Affected - Many (A) . FOOD shall be protected from contamination by storing the FOOD:

(1) In a clean, dry location;

(2) Where it is not exposed to splash, dust, or other contamination; and

(3) At least 15 cm (6 inches) above the floor.

,d+[DATE REDACTED].11 Miscellaneous Sources of Contamination.

FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts ,d+[DATE REDACTED] - ,d+[DATE REDACTED] .

,d+[DATE REDACTED].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.

(A) . refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

,d+[DATE REDACTED].12 Handwashing Sink, Installation.

(A) A HANDWASHING SINK shall be equipped to provide water at a temperature of at least 29.4 C (85 F) through a mixing valve or combination faucet.

,d+[DATE REDACTED].11 Using a Handwashing Sink.

(A) A HANDWASHING SINK shall be maintained so that it is accessible at all times for EMPLOYEE use.

During the initial kitchen tour on [DATE REDACTED] at 1:48 PM, nine sandwiches, individually packaged in plastic wrap and each labeled [DATE REDACTED], were observed in Walk-in Cooler #2. The Dietary Manager said these sandwiches were for residents' snacks and for adding to meal trays. The Dietary Manager asked the staff working on the trayline, when were the sandwiches made. Diet Aide #6 said she made them yesterday. The Dietary Manager reminded the staff that the use-by date had to be on the sandwich, not the date they were made.

During the initial kitchen tour on [DATE REDACTED] at 1:55 PM, Walk-in Cooler #3 had food thawing on a bottom shelf that was approximately three inches from the floor. The thawing food items included: 5 boxes of Frankfurters, 1 box of Ground Beef, and 2 boxes of Pork.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 70 015133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015133 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Ridge 420 Dean Drive Gardendale, AL 35071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 On [DATE REDACTED] at 5:10 PM, the residents' Dinner trayline was observed. Most plates had a scoop of cold chicken salad atop a stack of two bread slices. Also, on the same plate was a scoop of coleslaw, pickle garnish, and Level of Harm - Minimal harm or an uncovered bowl of hot Minestrone Soup. The entire plate was then covered with an insulated dome. potential for actual harm There was a one inch gap between the insulated dome and the top of the plate on several trays leaving food uncovered. Residents Affected - Many

On [DATE REDACTED] at 5:25 PM, the delivery of Dinner trays to residents on the East Hall was observed. The resident meal trays were being transported on an open cart. Several trays had gaps of approximately one inch between the dome lid and the top of the plate, therefore exposing the food so it was not covered.

In an interview on [DATE REDACTED] at 5:30 PM, the Dietary Manager said the soup bowls not covered because there were no bowl lids at the facility.

During a kitchen observation on [DATE REDACTED] at 11:09 AM, the handwashing sink between the 3-Compartment Sink and the entrance to the Dishwashing Room was observed to be tilted downward from the wall, so that dirty water could not go down the drain. Also, cold water was not dispensed when the knob was turned on, so the water was extremely hot when running from the faucet.

On [DATE REDACTED] at 5:50 PM, the shelf in Walk-in Cooler #3, which had thawing meats on [DATE REDACTED], was still in the same position. The distance from the floor was measured with the Regional Dietary Manager. The distance from the floor to the top of the shelf was three and one-half inches.

On [DATE REDACTED] at 11:00 AM, the PM [NAME] was asked how long the handwashing sink between the 3-Compartment Sink and the entrance to the Dishwashing Room had been broken. The PM [NAME] said it had been broken for at least a month.

On [DATE REDACTED] at 11:15 AM, the Dietary Manager was observed using the broken handwashing sink to wash her hands.

On [DATE REDACTED] at 11:25 AM, the AM [NAME] was observed washing her hands at the broken handwashing sink.

On [DATE REDACTED] at 11:28 AM, the AM [NAME] said the handwashing sink had been broken about three months.

On [DATE REDACTED] at 11:30 AM, the Dietary Manager was again observed using the broken handwashing sink to wash her hands. When asked if the cold water was available, the Dietary Manager turned the cold water knob to show that the cold water connection was not working.

On [DATE REDACTED] at 12:40 PM, Diet Aide #13 was observed making Ham Sandwiches for Resident Bedtime Snacks. Using a black fine-point marker, he had marked all of the plastic wrapped sandwiches with , d+[DATE REDACTED]. Diet Aide #13 said he had worked at the facility for just under a year. Diet Aide #13 said he did not know about Use By dates. Diet Aide #13 said the date he made the sandwiches, was the date he wrote

on the plastic wrap.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 70 015133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015133 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Ridge 420 Dean Drive Gardendale, AL 35071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 On [DATE REDACTED] at 12:45 PM, Diet Aide #14 was observed making Peanut Butter and Jelly Sandwiches for Resident Bedtime Snacks. Diet Aide #14 said he had been working at the facility for 2 or 3 months. Using a Level of Harm - Minimal harm or black fine-point marker, he had marked all the plastic wrapped sandwiches with PB ,d+[DATE REDACTED]. Diet Aide #14 potential for actual harm said the date was for today's date. He further said, Each day I make them, I put the date that I made them.

Residents Affected - Many On [DATE REDACTED] at 4:21 PM, the Dietary Manager was interviewed. The Dietary Manager said about a month ago, someone leaned on the sink and caused it to come off the wall. The Dietary Manager said it was bent down so the water was not going down the drain the correct way. When asked about the cold water, the Dietary Manager said the Health Department was there last month and Maintenance had to turn off the cold water in that area because there was a leak in the pipes under the 3-Compartment Sink that needed to be fixed. It was fixed, but the cold water to the hand sink had not been turned back on yet. When asked the problem with washing one's hands in a handwashing sink that was not draining dirty water down the drain, the Dietary Manager said possible cross-contamination due to back splash. When asked the problem with washing one's hands in a handwashing sink that had only hot water and no cold water, the Dietary Manager said the water can be too hot for washing one's hands the full 20 seconds. When asked the problem with storing food less than 6 inches from the floor; the Dietary Manager said rodents, not being able to clean underneath properly, and possible cross-contamination. When asked the problem with sending incompletely covered plates of food on open carts to serve residents on the halls; the Dietary Manager said loss of temperature and possible air-borne cross-contamination. Upon being asked the problem with food not being marked with a Use by Date, the Dietary Manager said staff would not know the right day to discard it.

On [DATE REDACTED] at 5:00 PM, the Registered Dietitian (RD) was interviewed. The RD said possible contamination was the problem with washing one's hands in a handwashing sink that was not draining dirty water down the drain. When asked the problem in using a handwashing sink that had only hot water and no cold water, the RD said the water temperature could not be adjusted so it could cause a burn and one may not wash their hands long enough. When asked the problem with storing food less than 6 inches from the floor; the RD said bugs, splash from cleaning products, dust, and possible contamination. When asked the problem with sending incompletely covered plates of food on open carts to serve residents on the halls, the RD said possible contamination. Upon being asked the problem with food not being marked with a Use by Date, the RD said staff would not know when they expired.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 70 015133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015133 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Ridge 420 Dean Drive Gardendale, AL 35071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0851 Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Level of Harm - Potential for minimal harm 29671

Residents Affected - Many Based on record review, interview, and Payroll Based Journal (PBJ) Report, the facility failed to report accurate staffing data from July 01, 2024 until September 30, 2024, to Centers for Medicare & Medicaid Services (CMS).

This affected one quarter of data reviewed during the survey.

Findings include:

The PBJ report generated for the quarter of 07/01/2024 through 09/30/2024 documented:

. This Staffing Data Report identifies areas of concern that will be triggered .

Metric .

Excessively Low Weekend Staffing . Triggered = Submitted Weekend Staffing data is excessively low .

On 03/10/2025 at 11:37 AM, a review of PBJ report revealed it triggered for excessively low weekend staffing for the 4th quarter of 2024.

An interview took place with the Administrator (ADM) on 03/10/2025, at 12:05 PM. During the interview, the ADM was questioned regarding the PBJ report that indicated low weekend staffing for the fourth quarter of 2024. The ADM clarified that the facility did not experience low weekend staffing during that period. She explained that administrative staff were on call during weekends and were expected to provide direct patient care if scheduled staff failed to report for duty. However, when this occurs, their time was not recorded as direct patient care, which led to the report reflecting low weekend staffing. The ADM said it was important to send accurate data to CMS to ensure the staffing report was correct.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 70 015133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015133 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Ridge 420 Dean Drive Gardendale, AL 35071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 39580 potential for actual harm Based on observations, interviews, and review of facility policies titled, Personal Clothing Handling, the Residents Affected - Few facility failed to ensure staff provided care to residents and handled supplies and linen in a manner to prevent

the possibility for cross-contamination of residents and their environment.

This deficient practice had the potential to affect 134 of 134 residents observed for infection control.

Findings include:

Review of a facility policy titled, Personal Clothing Handling, with a revision date of 03/01/2024 revealed the following:

POLICY

Resident/Patient . clothing that is process by the service location is cleaned and processed by the service location is cleaned and returned to the patient in a timely fashion.

PURPOSE

To ensure patient's personal clothing is properly laundered and processed to meet the needs of the patients .

On 03/05/2025 at 11:32 AM, an observation was made of Laundry Staff (LS) #47 on the East unit, front hall passing out residents' personal clothes. Clothes were on hangers on the clothes rack and were not covered.

On 03/05/2025 at 11:32 AM an interview was conducted with LS #47 who said, clothes on the rack should be covered when brought down the hall. LS #47 said the rack did not have a cover like the old one did. She further said, she guessed she could have covered the rack with a sheet. LS #47 said germs could get on the clothes when brought to the halls when not covered.

On 03/05/2025 at 4:07 PM an interview was conducted with the District Manager for Environmental Services (DMES). He said that when the clothes from laundry should have a drape over them when they were delivered to the residents. The DMES further said when the resident's clothes were transported without a drape or cover on them, there was a potential for cross-contamination.

21055

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 70 015133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015133 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Ridge 420 Dean Drive Gardendale, AL 35071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20304 potential for actual harm Based on observation, interview, and the United States (U.S.) Food and Drug Administration (FDA) 2022 Residents Affected - Many Food Code; the facility failed to ensure:

1.) the air filters for two of two Ice Machines were cleaned as recommended by the manufacturer;

2.) an in-use Handwashing Sink in the kitchen was repaired;

3.) a new fuse was obtained for the Dishwashing Machine;

4.) a Plate Lowerator (one of one), which would help keep food warm for the residents, was repaired.

This had the potential to affect 132 of 132 residents receiving meals from the facility's kitchen.

Findings Include:

The U.S. FDA 2022 Food Code included the following:

. 4-501.11 Good Repair and Proper Adjustment.

(A) EQUIPMENT shall be maintained in a state of repair .

During the initial kitchen tour on 03/02/2025 at 1:58 PM, the Dietary Manager (DM) said the dishwashing machine was normally a hot sanitizing rinse machine, but it had been temporarily converted to a chemical sanitizing machine.

On 03/03/2025 at 11:21 AM, the Dietary Manager said the dishwashing machine's heated final rinse was not working because it needed a replacement fuse for the fuse box. The blown fuse was discovered in September 2024. The Dietary Manager said the previous Maintenance Director left about October 2024, but

the (Senior) Regional Maintenance Director was currently at the facility.

During the initial kitchen tour on 03/02/2025 at 1:45 PM, the ice machine in the kitchen had two air filters located on the front of the machine, which needed to be cleaned or replaced. There was a thick grey residue

on the exposed areas of the filters. The DM agreed the filters needed to be cleaned.

On 03/02/2025 at 2:15 PM, the ice machine on East Wing was observed with Certified Nursing Assistant (CNA) #7. The ice machine had two very dirty air filters on the front of the machine. A thick grey residue was built-up on the air filters. Each frame holding an air filter on the ice machine had the following directive: Clean Air Filter Twice A Month. CNA #7 agreed the filters were dirty.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 70 015133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015133 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Ridge 420 Dean Drive Gardendale, AL 35071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 On 03/03/2025 at 1:31 PM, the Senior Regional Maintenance Director was actively working on repair of the East Wing's ice machine. When asked about the air filters located on front of the ice machine, he said the Level of Harm - Minimal harm or maintenance of the ice machine air filters should be regulatory for them. The Senior Regional Maintenance potential for actual harm Director additionally said those filters were cleanable. When asked about the fuse for the dishwashing machine, the Senior Regional Maintenance Director said he was not aware of that problem. Residents Affected - Many

During a kitchen observation on 03/03/2025 at 11:09 AM, the handwashing sink between the 3-Compartment Sink and the entrance to the Dishwashing Room was observed to be tilted downward from the wall which prevented dirty water from going down the drain properly. Also, cold water was not dispensed when the knob was turned on, so the water was extremely hot when running from the faucet. The sink was loose from the wall. The sink was one of three handwashing sinks observed in the kitchen. The Dietary Manager said the broken handwashing sink had not yet been reported to Maintenance.

On 03/03/2025 at 3:20 PM, the Administrator was asked about the status of a fuse for the dishwashing machine. The Administrator said an Assistant Maintenance person was supposed to have contacted their vendor in mid-January 2025 about supplying one. However, that Assistant Maintenance person terminated employment with the facility last week. The Administrator said she planned to get the Senior Regional Maintenance Director to check on that for her.

On 03/04/2025 at 11:00 AM, the PM [NAME] was asked how long the handwashing sink between the 3-Compartment Sink and the entrance to the Dishwashing Room had been broken. The PM [NAME] said it had been broken for at least a month.

On 03/04/2025 at 11:15 AM, the Dietary Manager was observed using the broken handwashing sink to wash her hands.

On 03/04/2025 at 11:25 AM, the AM [NAME] was observed washing her hands at the broken handwashing sink.

On 03/04/2025 at 11:28 AM, the AM [NAME] said the handwashing sink had been broken about three months. The AM cook further said she did not like leaning over so far to wash her hands, because it hurt her back.

On 03/04/2025 at 11:30 AM, the Dietary Manager was again observed using the broken handwashing sink to wash her hands. When asked if the cold water was available, the Dietary Manager turned the cold water knob to show that the cold water connection was not working. The Dietary Manager said she told Maintenance about the broken handwashing sink on Monday (03/03/2025).

On 03/04/2025 at 11:35 AM, a plate lowerator was observed on the left side of the steam table, but it was not plugged in and did not seem to be in use, as there were no plates in it. The plate lowerator seems to be in use as a counter with the meal temperature sheet, eyeglasses, and a bi-metallic stemmed thermometer laying on top.

On 03/04/2025 at 1:25 PM, the Dietary Manager was asked about the plate lowerator. The Dietary Manager said the plate lowerater had been broken since she had started working at the facility, about one and a half years ago.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 70 015133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015133 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Ridge 420 Dean Drive Gardendale, AL 35071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 On 03/05/2025 at 4:21 PM, the Dietary Manager was interviewed. The Dietary Manager said Maintenance was usually alerted of problems and broken equipment by TELS, a computer system. The Dietary Manager Level of Harm - Minimal harm or also said they can call if it is an emergency. The Dietary Manager further said right now they only had a potential for actual harm Maintenance Assistant. The Dietary Manager said she alerted Maintenance about the handwashing sink on Monday, March 3, 2025. The Dietary Manager said about a month ago, someone leaned on the sink and Residents Affected - Many caused it to come off the wall. The Dietary Manager said it was bent down so the water was not going down

the drain the correct way. When asked about the cold water, the Dietary Manager said the Health Dept was here last month and Maintenance had to turn off the cold water in that area because there was a leak in the pipes under the 3-Compartment Sink that needed to be fixed. It was fixed, but the cold water to the hand sink has not been turned back on yet. When asked the problem with washing one's hands in a handwashing sink that was not draining dirty water down the drain, the Dietary Manager said possible cross-contamination due to back splash. When asked the problem with washing one's hands in a handwashing sink that has only hot water and no cold water, the Dietary Manager said the water can be too hot for washing one's hands the full 20 seconds. The Dietary Manager said she alerted Maintenance about the broken plate lowerator when she started working at the facility, about a year and a half ago. The Dietary Manager said the plate lowerator was broken when she arrived at the facility. The Dietary Manager said she alerted Maintenance about the fuse for

the dishwashing machine in September 2024. The Dietary Manager said about 5 months ago, the service company came to check the dishwashing machine and found that the red fuse was blown and the facility had to order it.

On 03/05/2025 at 5:00 PM, the Registered Dietitian (RD) was interviewed. The RD said possible contamination was the problem with washing one's hands in a handwashing sink that was not draining dirty water down the drain. When asked the problem in using a handwashing sink that had only hot water and no cold water, the RD said you cannot adjust the water temperature so it could cause a burn and one may not wash their hands long enough.

On 03/05/2025 at 5:31 PM, the Maintenance Assistant was interviewed. The Maintenance Assistant said he routinely went to the Kitchen, Monday through Friday, to check the fire equipment and that he was notified of problems or broken equipment via the work orders sent through the TELS computer system. The Maintenance Assistant said he just heard about the handwashing sink yesterday. He further said they did put

a work order in, but we have been so busy this week that I have not had a chance to look at the work orders.

The Maintenance Assistant did not know how the handwashing sink had been broken and he did not know about the cold water not working for the handwashing sink. The Maintenance Assistant said, if washing in a sink that is not draining dirty water down the drain, then hands are not getting clean. The Maintenance Assistant said he had not been notified about the plate lowerator. The Maintenance Assistant said he thought

the fuse had been ordered for the dishwashing machine and it should have been received by now.

On 03/05/2025 at 5:47 PM, the Senior Regional Maintenance Director was interviewed. He said TELS was their guide for regular preventative maintenance and it was how Maintenance was alerted of problems and broken equipment. The Senior Regional Maintenance Director said the life of the ice machine was affected by the maintenance of things like the air filters. The Senior Regional Maintenance Director said the handwashing sink in the kitchen was bent and had a screw loose. He further said it was unsanitary to wash one's hands in a sink that is not draining dirty water down the drain. He had not been notified about the plate lowerator. The Senior Regional Maintenance Director said he had found an electrical vendor to supply a replacement fuse for the dishwashing machine.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of 70 015133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015133 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Ridge 420 Dean Drive Gardendale, AL 35071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 During a follow-up interview on 03/06/2025 at 4:13 PM, the Senior Regional Maintenance Director said the ice machine's air filters need to be kept clean to help keep the compressor mechanics cool. The Senior Level of Harm - Minimal harm or Regional Maintenance Director further said it was an expensive machine and this would help make it last potential for actual harm longer, it should last 10 or [AGE] years. The Senior Regional Maintenance Director also said the ice machines have a notation on the front to clean the air filters every two weeks. Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of 70 015133

F-F609-Reporting of Alleged Violations. The IJ began on 07/25/2023 and continued until 08/21/2023 when the facility implemented corrective actions to correct the identified deficient practice and prevent recurrence; thus, immediate jeopardy past noncompliance was cited.

This deficiency was cited as a result of a Facility Reported Incident/Complaint/Report Number AL00044983.

Findings include:

Cross-reference

F-F689 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 70 015133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015133 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Ridge 420 Dean Drive Gardendale, AL 35071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39580 potential for actual harm Based on observation, interview, record review, and review of the facility's policy titled, PROCEDURE - Residents Affected - Few RESPIRATORY EQUIPMENT/SUPPLY CLEANING/DISINFECTING the facility failed to ensure Resident Identifier (RI) #94's Oxygen (02) concentrator water bottle was not empty during the administration of oxygen.

This affected one of one sampled resident identified with humidified oxygen.

Findings Include:

A review of the facility's policy titled, PROCEDURE - RESPIRATORY EQUIPMENT/SUPPLY CLEANING/DISINFECTING with a revised date of 07/15/21, revealed the following: . 5. Schedule for Supply Changes: . Item . Oxygen Humidifiers . Frequency . Every 7 days . PRN . For soiling .

RI #94 was readmitted to the facility on [DATE REDACTED], with diagnoses including: Chronic Respiratory Failure with Hypoxemia, Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure.

A review of RI #94's 14-Day Assessment Minimum Data Set (MDS) dated [DATE REDACTED] revealed RI #94's Brief

Interview for Mental Status score was 10 of 15 which indicated RI #94 had moderate cognitive impairment.

A review of RI #94's March 2025 Physician's Orders revealed the following: . Start Date . 11/29/24 Oxygen at 4 Liters/Minute Nasal Cannula continuously .

On 03/05/2025 at 09:24 AM, during the tour, RI #94's oxygen (O2) concentrator's humidification bottle was observed empty during administration of oxygen. The humidification bottle was dated 02/24/2025. The oxygen tubing was dated 03/03/2025.

On 03/03/2025 at 11:11 AM, during the initial tour, RI #94's oxygen (O2) concentrator's humidification bottle was observed empty during administration of oxygen.

On 03/05/2025 at 11:54 AM, an interview with the Director of Nursing (DON) was conducted. RI #94's oxygen humidification bottle was observed with the DON. The DON said the humidification bottle was dated 02/24/2025. The DON said the humidification bottle should be changed every 7 days when oxygen tubing was changed. The DON said the nurse that changed the oxygen tubing on 03/03/2025 did not follow the facility's policy because they did not change the oxygen humidifier bottle on 03/03/2025. The DON said oxygen infusing without humidification could dry out the resident's mucus membranes and cause bleeding.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 70 015133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015133 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Ridge 420 Dean Drive Gardendale, AL 35071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48195 safety Based on interviews, resident record review, and review of a facility policy titled Behavioral Health Care Residents Affected - Few Services, the facility failed to ensure staff utilized and implemented behavior management care plan approaches to manage Resident Identifier (RI) #60's verbal behaviors, outbursts, and cursing.

Specifically, on 07/25/2023 RI #60 was outside in the smoking area with other residents (RI #287 and RI #488) and staff Certified Nursing Assistant (CNA #39 and CNA #41). RI #60 was cursing and calling staff names. CNA #41 failed to respond to RI #60 calmly and gently, and instead, CNA #41 picked up an ashtray and threw it at RI #60. The ashtray did not hit RI #60 but caused RI #60's behavior to escalate. RI #60 picked up the ashtray and threw it back at CNA #41. The ashtray did not hit the CNA, but the ashtray did hit another resident, RI #287 on the head and caused injury.

It was determined the facility's noncompliance with one or more requirements of participation had cause, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 443.40 Behavioral Health Services.

On 03/19/2024 at 6:20 PM, the Administrator and Director of Nursing (DON), were provided a copy of the Immediate Jeopardy Template and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Behavioral Health at

F-F740-Behavioral Health Services. The immediate jeopardy began on 07/25/2023 and continued until 08/21/2024 when the facility implemented corrective actions to remove the immediacy; thus, immediate jeopardy past noncompliance was cited.

The facility failed to manage other residents' behavioral concerns to prevent physical and verbal abuse in instances not rising to the immediate jeopardy level.

2.) Specifically, on 05/24/2023 RI #487, a resident with a history of behaviors had an altercation with a staff member which resulted in RI #487 being verbally abused by a staff member. Following the incident on 05/24/2023, the facility did not review RI #487's care plan to determine whether additional interventions were needed to manage RI #487's behaviors. On 07/01/2023 RI #487 had an altercation with his/her roommate, RI #41, which resulted in a fractured left finger.

3.) On 09/12/2024 RI #339 stabbed his/her roommate RI #3 with a pen causing pain and bleeding and RI #3 had to be transported to the hospital for evaluation. RI #339's care plans did not include the level of supervison required to ensure the safety of RI #339's roommate or other residents in the facility and did not include any focus areas, interventions, approaches, or guidance to staff to address physical aggression, throwing things, night terrors, flashbacks, or sleeplessness.

RI #60, RI #487, and RI #339 were three of four residents sampled for behavioral concerns.

The facility's failure to manage RI #60's, RI #487's, and RI #339's behaviors resulted in injury of RI #41, RI #287, and RI #3, three of 29 residents sampled.

Findings include:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 70 015133 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 015133 B. Wing 03/19/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Ridge 420 Dean Drive Gardendale, AL 35071

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Cross-reference