Magnolia Manor Of Columbus Nursing Center - East

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

any behaviors and was dependent on staff for toileting hygiene, shower/bathing, lower body dressing, and personal hygiene. It was recorded that Resident R3 required substantial/maximal assistance from staff for rolling left and right and from lying to sitting on the side of the bed, and had not sustained a fall since admission.A

review of Resident R3's FRI, dated 3/25/2025 and provided by the facility, revealed, [Resident R3] fell, causing an injury, specifically a hematoma and laceration, while receiving care . Further review of the FRI revealed that although Resident R3 and staff were interviewed, there were no additional residents who were interviewed or assessed for injuries.4. A review of Resident R5's undated Face Sheet, located in the EMR under the Face Sheet tab, indicated Resident R5 was readmitted from the hospital on 7/10/2025 after falling with injuries. Diagnoses included traumatic subarachnoid hemorrhage with fracture of the base of the skull and fracture of the vault of the skull.A review of Resident R5's significant change MDS, with an ARD of 7/18/2025 and located in the EMR under the MDS tab, revealed Resident R5 was unable to complete the BIMS. Staff assessment of cognitive skills for daily decision making revealed Resident R5 was moderately impaired. It was recorded Resident R5 was independent with all activities of daily living and mobility.A review of Resident R5's FRI, dated 7/08/2025 and provided by the facility, revealed, . Nurse on duty was notified by another staff member that [Resident R5] was on the floor in the hallway . noted to have decreased level of consciousness with hematoma to left posterior portion of head . Resident R5 was admitted to hospital for post follow-up diagnostics. Review of the five-day follow-up it was revealed that . another resident was in the vicinity stating, this is what you get for coming into my room. Due to the lack of witnesses to the event, it is undetermined whether this resident contributed to the fall occurrence. Further

review of the FRI revealed that although staff were interviewed, no additional residents were interviewed or assessed for injuries. Resident R5 was unable to be interviewed due to her condition.5. A review of Resident R6's undated Face Sheet, located in the EMR under the Face Sheet tab, indicated Resident R6 was admitted to the facility on [DATE REDACTED] with diagnoses that included chronic obstructive pulmonary disease (COPD), major depressive disorder, and diabetes mellitus with neuropathy.A review of Resident R6's quarterly MDS, with an ARD of 5/14/2025 and located in the EMR under the MDS tab, revealed Resident R6 had a BIMS score of one out of 15, which indicated Resident R6 was severely cognitively impaired. It was recorded that Resident R6 did not exhibit behaviors.A review of Resident R6's FRI, dated 3/27/2025 and provided by the facility, revealed, [Resident R6] verbalized staff was being rough with her while providing care . Further review of the FRI revealed that although Resident R6 and staff were interviewed, there were no additional residents who were interviewed or assessed for injuries.During an

interview on 8/27/2025 at 9:48 am, the Director of Nursing (DON) was asked if any additional residents were interviewed or assessed during the FRI investigations. The DON stated she participated in a couple of

the investigations, but not all, because they were before she was employed at the facility. The DON confirmed she did not do any other residents' interviews or physical assessments. Upon review of the FRIs,

the DON was unable to provide documented evidence that resident interviews and assessments had been completed with each incident.During an interview on 8/29/2025 at 2:46 am, the Administrator was asked what his expectations were related to investigations into Facility Reportable Incidents. The Administrator stated he would expect a thorough investigation, including resident interviews and assessments, to provide insight into the incidents.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Manor of Columbus Nursing Center - East

2010 Warm Springs Rd Columbus, GA 31904

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 0656

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility document review, the facility failed to implement the care plan for one of three residents (R) (Resident R3) reviewed for falls. Resident R3's care plan instructed staff to use two people for bed mobility. Certified Nurse Aide (CNA)1 provided care alone, and as a result, Resident R3 fell from the bed during care, sustaining a hematoma and laceration from the fall.Findings included:A review of the facility's policy titled Care Planning-Interdisciplinary Team, revised October 2016, revealed, A comprehensive person-centered care plan shall be developed and implemented for each resident that includes measurable objectives and time frames that meet a resident's medical, nursing, and mental and psychosocial needs that are identified

in the comprehensive assessment.A review of the electronic medical record EMR) revealed that Resident R3 was admitted to the facility on [DATE REDACTED]with diagnoses that included disease of the spinal cord, rheumatoid arthritis, and spondylosis with myelopathy, cervical region.A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident R3 had a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated the resident was severely cognitively impaired; that Resident R3 was assessed as being dependent on staff for toileting hygiene, shower/bathing, lower body dressing, and personal hygiene and requiring substantial/maximal assistance from staff for rolling left and right and from lying to sitting on side of bed. It was recorded that Resident R3 had not sustained a fall since admission.A review of the Care Plan dated 2/18/2025 revealed that Resident R3 required assistance with her activities of daily living (ADL) care due to polyneuropathy and chronic pain in her knees. Approaches included assisting Resident R3 to turn/reposition with routine rounds; Resident R3 could assist herself with two-person assistance; and bed mobility: two-person extensive assistance was required.A review of Resident R3's Facility Reportable Incident (FRI), dated 3/25/2025 and provided by the facility, revealed, . [Resident R3] sustained a fall during care on 3/24/2025 and sustained hematoma and a laceration to the right side of the head. [Resident R3] was transferred to the emergency room for further evaluation.

The CNA assigned to care for the resident stated she provided ADL care to the resident without any additional assistance as noted in [Resident R3]'s plan of care .An attempt to contact CNA1 for an interview on 8/27/2025 at 2:30 pm revealed that CNA1's phone number was no longer in service.A review of CNA1's Written Statement, located in the FRI investigative folder and provided by the facility, revealed that CNA1 completed a written statement on 3/24/2025. The statement recorded that CNA1 was providing care to Resident R3.

During the care, CNA1 pulled Resident R3 towards her to turn Resident R3 onto her left side. As CNA1 was cleaning Resident R3's backside, she rolled off the bed. It was recorded that there was no staff partner assisting with Resident R3's care.During an interview on 8/27/2025 at 2:40 pm, Registered Nurse (RN)1 was asked if CNA1 had asked anyone for assistance with Resident R3's care. RN1 stated No. RN1 stated that CNA1 did not ask for help until after

the resident fell. RN1 confirmed that Resident R3 was a two-person assist with all ADLs.During an interview on 8/27/2025 at 9:48 am, the Director of Nursing (DON) stated she expected that staff follow the residents' care plan for those who require extensive assistance.During an interview on 8/29/2025 at 2:46 pm, the Administrator stated he expected CNA1 to follow Resident R3's care plan, but also to look at residents' changes in care.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Manor of Columbus Nursing Center - East

2010 Warm Springs Rd Columbus, GA 31904

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 0689 Level of Harm - Actual harm

those who require extensive assistance.During an interview on 8/29/2025 at 2:46 pm, the Administrator was asked what his expectation was related to the incident with Resident R3. The Administrator stated he expected CNA1 to follow Resident R3's care plan, but also to look at residents' changes in care.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Manor of Columbus Nursing Center - East

2010 Warm Springs Rd Columbus, GA 31904

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 0925

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interviews, and record review, the facility failed to maintain a facility-wide effective pest control program for the current facility population of 89 residents. This failure had the potential to lead to further pest infestation in the facility and feelings of discomfort or spread of infection among the residents.Findings included:A review of the facility's policy titled, Pest Control dated 12/2012, revealed, . It is the intent of (name of facility) to ensure that all facilities have an effective Pest Control Program .A review of the facility's Resident Council Minutes for the past year, provided by the facility, revealed:2/11/2025 - One resident's family complained of rodents in the facility. The facility's response was to schedule an exterminator monthly.2/20/2025 - List of old business: Exterminator for bugs and rodents.7/18/2025 - under list of old business (resolved): Pest control-resolved and on-going.A review of the facility's Pest Control Checklist revealed the following pest/rodent sightings:3/27/2025- three residents' rooms on South 2 unit.

Mice.4/3/2025- one resident's room on South 2 unit. Mice.4/9/2025- one resident's room on South 2 unit.

Mice.4/24/2025- one resident's room on South 2 unit. Mice.4/29/2025- one resident's room on South 2 unit.

Mice.5/15/2025- two residents' rooms on South 2 unit. Mice.6/9/2025-one resident's room on North 2 unit.

Roaches.6/10/2025-one resident's room on South 2 unit. Mice.6/13/2025- one resident's room on South 2 unit. Mice.7/1/2025- two residents' rooms on South 1 unit. Roaches.7/4/2025- one resident's room on South 2 unit. Mice.7/7/2025- two residents' rooms on North 2 unit. Bugs.7/22/2025- one resident's room on South 2 unit. Mice.A group interview was conducted on 8/28/2025 at 3:37 pm with the [NAME] President of Physical Plant, Director of Maintenance, Maintenance Administrative Assistant, and Maintenance staff. The group confirmed the facility had been experiencing an infestation of field mice. The group confirmed the facility had changed pest control/extermination contractors approximately three months ago and had an intensive six-week eradication conducted. The group confirmed the facility continues with service twice monthly, and anytime there is a spotting, the company is on-call for treatment. The infestation was elevated to the quality assurance committee before changing contractors. Monitoring was initiated throughout the building, and training was held with staff and residents concerning eliminating food and environmental issues that attract mice.During a tour of the facility on 8/28/2025 at 3:45 pm, Resident R10 and Resident R11, residents who have witnessed mice in their rooms, reported that it had been a couple of weeks since they had spotted any mice or heard any other residents mention mice. There were no mice observed during the survey dates of 8/26/2025, 8/27/2025, 8/28/2025, and 8/29/2025.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet