Magnolia Creek Nursing And Rehabilitation
MAGNOLIA CREEK NURSING AND REHABILITATION in COVINGTON, TN — inspection on August 12, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a telephone interview on [DATE] at 12:06 AM, CNA A stated on [DATE]-[DATE] she frequently observed Resident #1 in bed sleeping, and sitting on the side of the bed, which was in the lowest position. CNA A stated Resident #1 would get out of bed at times and wander around the Memory Care Unit. CNA A confirmed she was not always monitoring him during the night ([DATE]-[DATE]) because there were 15-16 other residents on the Memory Care Unit. CNA A was asked if she had received education on abuse which included recognizing and reporting an injury of unknown origin. CNA A confirmed she was not aware a head injury could be a sign of abuse.
During an interview on [DATE] at 3:56 PM, Registered Nurse (RN) S stated her last abuse in-service was more than a year ago as she had just worked a minimal schedule while attending school. RN S stated she did not recall being given education related to reporting an injury of unknown origin as suspected abuse.
During an interview on [DATE] at 4:49 PM, LPN U stated the last in-service training she received was within the past 3 months. LPN U did not recall specific training on injury of unknown origin being included in the reporting requirements for abuse.
During an interview on [DATE] at 5:16 PM, RN N stated the last in-service on abuse was within the past year. RN N acknowledged she was not aware of the requirement to report an injury of unknown origin within a specified time frame.
During a telephone interview on [DATE] at 11:00 AM, RN C stated on [DATE] she worked 6:00 AM to 6:00 PM on the Memory Care Unit. RN C stated Resident #1 did not have a raised area on his left forehead when she left work on [DATE]. RN C stated during morning (6:00 AM) report on [DATE], LPN B reported Resident #1 had a raised area on his left forehead. LPN B reported Resident #1 had not had a fall and she didn't know what caused the raised area on his forehead. RN C stated LPN B did not complete an event report and did not ask her to complete the event report for the raised area. RN C was asked if she had reported the injury to Administration. RN C replied, No. RN C was asked if she had been educated on recognizing abuse and reporting abuse. RN C acknowledged she had received abuse education, and she had provided abuse education during her employment in the facility. RN C was asked what she was required to do if a resident had an injury no one had witnessed happening and the resident was unable to explain how the injury occurred. RN C replied, .If the injury needed treatment, I would call the doctor.I would fill out an incident report and give it to the Unit Manager.
During an interview on [DATE] at 1:45 PM, the Director of Nursing (DON) acknowledged she was aware Resident #1 was sent to the hospital on [DATE] for evaluation of a raised area on his left forehead and she did not have any concerns with the assessment and intervention provided to Resident #1 by nursing staff.
The DON was asked if the facility had determined the cause of Resident #1's injury to his forehead.
The DON stated there was not an injury or fall and staff concluded the raised area was probably an allergic reaction to a mosquito bite.
The DON was asked if staff provided monitoring for Resident #1 at all times during the night of [DATE]-[DATE].
The DON stated staff did not monitor at all times.
The DON was asked if Resident #1's injury of unknown cause had been reported to the SSA within two hours and the facility investigation results reported to the SSA within 5 business days.
The DON confirmed the injury had not been reported to the SSA and investigated.
During an interview on [DATE] at 2:42 PM, the Administrator stated as the Administrator and Abuse Coordinator she was responsible to ensure allegations of abuse, known or suspected, are reported to the SSA in the required time frame.
Refer to F-F684
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Magnolia Creek Nursing and Rehabilitation
1992 Hwy 51 S Covington, TN 38019
SUMMARY STATEMENT OF DEFICIENCIES
During a telephone interview on [DATE] at 12:06 AM CNA A stated she observed Resident #1 in bed sleeping, and at times sitting on the side of the bed, which was in the lowest position. CNA A stated Resident #1 could get up with the bed in the low level and would wander around the Memory Care Unit. CNA A confirmed she checked on Resident #1 during the night and was not always monitoring him, because there were 15-16 other residents on the memory care unit. CNA A stated, .I didn't see the place [hematoma] on his head the night before. CNA A was asked if she had received education on abuse which included injury of unknown origin, such as a knot on a resident's head with unknown cause. CNA A confirmed she was not aware a head injury could be a sign of abuse. CNA A confirmed she had not been asked to provide a statement about the incident with Resident #1 until [DATE].
During an interview on [DATE] at 1:45 PM, the DON stated the Staff Development Coordinator (SDC) was in the building on [DATE] and told her about Resident #1 getting sent out per family request.
The DON concluded she did not have any concerns with the assessment and intervention provided to Resident #1 by nursing staff.
The DON was asked if Resident #1 had an injury of unknown origin which required investigation.
The DON stated Resident #1's injury (hematoma) was not caused by an injury or fall and was thought to be a mosquito bite.
The DON acknowledged Resident #1 was not monitored at all times during the night of [DATE]-[DATE].
The DON stated the facility started an investigation after APS (Adult Protective Services) came to the facility and told them about the investigation ([DATE]).
The DON was asked if the facility was required to investigate injuries of unknown origin.
The DON put her head down for a minute and then got up from the table and left the room.
During an interview on [DATE] at 2:42 PM, the Administrator stated when a resident has an injury that cannot be explained the facility would be required to investigate.
Refer to F-F684
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Magnolia Creek Nursing and Rehabilitation
1992 Hwy 51 S Covington, TN 38019
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on [DATE] at 5:16 PM, RN N stated when
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Magnolia Creek Nursing and Rehabilitation
1992 Hwy 51 S Covington, TN 38019
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 7/25/2025 at 1:45 PM, the DON was asked if staff were required to complete an event note for abnormal skin issue findings or injuries.
The DON confirmed staff were required to complete an event note if no one could explain the bruising or injury.
The DON stated RN C notified the NP on 5/25/2025 and obtained an order to transfer Resident #1 to the hospital at the wife's request.
The DON was asked if neuro checks should be documented as normal if the patient/resident does not wake up during the assessment and the patient/resident was unable to complete the assessment.
The DON replied, .No, it would be documented as abnormal findings.the person's ability to complete the assessment could depend on their baseline.
The DON was asked if she considered checking a patient's BP as part of the neuro check process was professional standards of practice.
The DON replied, .yeah.BP is documented in the vital signs section of the record [EHR].
The DON confirmed nurses should not document an assessment on a resident using information provided to them by another nurse or staff member.
The DON was asked to review the transfer form completed on 5/25/2025 and determine which provider was notified for orders to send Resident #1.
The DON stated the nurse documented notification to the NP.
The DON confirmed notification to the provider should not be documented unless the provider was notified.
During a telephone interview on 7/25/2025 at 4:15 PM, LPN T stated she had worked with RN C on occasion and had to help RN C with documenting in the electronic health record. LPN T concluded, .[Named RN C] has lots of trouble on the computer.she forgets how to get in and how to complete documentation. LPN T confirmed she has documented assessments completed by RN C without performing the assessment herself.
During a telephone interview on 7/25/2025 at 6:09 PM, the NP stated the facility had not called her on 5/25/2025 to discuss Resident #1's change of condition or request an order to transfer the resident to the ER.
Refer to
Facility ID: