Magnolia Manor Methodist Nsg C
Inspection Findings
F-Tag F0604
F 0604
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, staff interviews and the facility policy titled Restraints/Bed Rails, the facility failed to ensure one resident (R) (Resident R1) from a sample of 11 residents was free from being restrained with a gait belt while in a wheelchair. The deficient practice placed Resident R1 at risk of adverse clinical outcomes.
Findings includeReview of the policy Restraints/Bed Rails dated October 2016, documented, under Intent:
It is the intent of the (named) facility that right of residents to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms is honored at all times.Review of the medical records revealed Resident R6 was admitted to the facility on [DATE REDACTED], with the following diagnoses that included but are not limited to type 2 diabetes mellitus, mood disorder, hypertension, chronic obstructive pulmonary disease, and benign prostatic hyperplasia.Review of
the quarterly Minimum Data Set (MDS) for Resident R6 with an Assessment Reference Date (ARD) of 11/19/2025 revealed a Brief Interview for Mental Status (BIMS) score of 1 which indicated severe cognitive impairment.
Review of the care plan dated 6/11/2025 revealed Resident R6 showed signs and symptoms of cognitive decline with most recent Basic Interview for Mental Status test score of 5 compared to 9 on 3/10/2025. Care Plan Approaches documented, set expectations and limits for resident; respect resident rights to make decisions.Review of the progress notes dated 11/10/2025 through 1/11/2026 revealed a situation involving staff using a gait belt to restrain Resident R6 to his wheelchair. The responsible party was notified about the incident, and the resident did not sustain any injuries.Observation on 1/27/2026 at 1:06 PM revealed Resident R6 was sitting
in a high back wheelchair with leg rest and foot pedals. Resident R6 was at a table being assisted with lunch.During
an interview on 1/29/2026 at 12:47 PM with Licensed Practical Nurse (LPN) HH revealed that she received
a call from Certified Nursing Aide (CNA) II who informed her of Resident R6 being tied to a wheelchair with a gait belt. LPN HH stated she immediately called LPN MM Unit Manager who notified the Director of Nursing (DON.)Interview on 1/29/2026 at 2:28 PM with CNA II revealed that Resident R6 was up because he kept getting out of bed, even with mats at the bedside and was placed in his wheelchair. CNA II stated Resident R6 started yelling about wanting to go to bed and he was a Hoyer lift transfer. CNA II stated when she was hooking the pad to
the lift, she saw the gait belt was wrapped around the top portion of the resident and the outer part of the back of the wheelchair. CNA II confirmed she immediately notified LPN HH, removed the gait belt and placed Resident R6 in his bed. Interview on 1/29/2026 at 3:16 PM with the Director of Nursing (DON) revealed that CNA DD was terminated for substantiated abuse. Interview on 1/29/2026 at 4:14 PM with the Administrator revealed that it is her expectation that no residents be restrained.
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
F-Tag F0880
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm or potential for actual harm
Based on record reviews, interviews and the facility policy titled Surveillance for Infections, the facility failed to follow the Department of Public Health (DPH) recommendations for diagnostic testing for 33 symptomatic residents on six of six Units (Unit 1, Unit 2, Unit 3, Unit 4, Unit 5, Unit 6) involved in an epidemiological qualified infectious disease outbreak. The deficient practice increased the risk for continued spread of infection.Findings includeReview of the policy Surveillance for Infections revised September 2017 documented under Policy Interpretation and Implementation: 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infections, to guide appropriated interventions and to prevent future infections. 8. a.
The Infection Preventionist and the Attending Physician will determine if laboratory tests are indicated, and whether special precautions are warranted.Review of the gastrointestinal illness (GI) outbreak synopsis provided by the facility, documented the Department of Public Health (DPH) was contacted on 12/12/2025 regarding guidance for a potential outbreak of Norovirus. Review of the Infection Outbreak Mapping document for the GI symptoms indicated six of six units were affected.Review of the Line listing of resident and staff with symptoms dated 12/9/2025 through 12/17/2025 documented the residents and staff that developed symptoms of nausea and/or vomiting and diarrhea during that time frame. There was a total of 33 residents and 13 staff members listed with the final date of symptom onset of 12/17/2026 affecting a resident. Review of the communication with DPH dated 12/12/2025 documented that DPH was contacted for guidance and reporting for an outbreak of possible Norovirus without a diagnostic confirmation. DPH responded on 12/15/2025 with a recommendation for individuals who are experiencing diarrhea to receive testing and asked if the facility was contracted with a commercial lab.Review of the physician standing order dated 1/28/2026 documented that if the facility has any notification with treatment or testing recommendations sent by the health department or other entities, to document that you have received them and that you have sent (preferably fax) to the Physician and retain a copy at the facility for his next visit. This will prevent communication errors. In addition, it was documented that staff may also call and let him know
the fax has been sent.During an interview on 1/28/2026 at 10:28 AM with LPN AA Quality Assurance Director/Infection Preventionist, it was revealed that there were 33 residents and 13 staff with symptoms that included a combination of nausea and/or vomiting, diarrhea, and some with temperatures.During an
interview on 1/29/20261/28/2026 at 11:28 AM with the Medical Director/Physician (MD) revealed that he routinely does not order stool samples for culture. The patients had diarrhea for 2-3 days and the treatment
they were getting was fluids, Imodium and Zofran. MD stated that he was unaware of the DPH recommendation to collect stool samples and if he was informed that he would follow the DPH recommendation. During an interview on 1/28/2026 at 12:07 PM, the Nurse Practitioner (NP) revealed she saw some of the residents at the facility with vomiting/diarrhea during the outbreak in December 2025. NP stated she was aware of the recommendation to test for Norovirus but declined the recommendation for the residents under her care. NP stated the treatment plan would be the same and the residents were already receiving treatment from the primary care provider. NP stated by the time the recommendation was received from DPH and communicated there were no longer any residents with signs and symptoms.During
an interview on 1/29/2026 at 3:16 PM with the Director of Nursing (DON), it was revealed she was not aware that the Infection Preventionist nurse had listed a diagnosis for DPH and should have listed only the symptoms. The DON confirmed the physician should have been informed of the DPH recommendation.During an interview on 1/29/2026 at 4:14 PM with the Administrator, it was revealed that
she did not know the type of virus in the facility. The Administrator confirmed the report to DPH
Residents Affected - Many
MAGNOLIA MANOR METHODIST NSG C in AMERICUS, GA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in AMERICUS, GA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from MAGNOLIA MANOR METHODIST NSG C or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.